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_excep_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_3m_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_ltcp_1m	mrx_tier_extd_days_yn	mrx_tier_lbl_4	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	mrx_tier_gap_cost_share	mrx_tier_gap_all_drug_yn	mrx_tier_gap_drug_type_lmtd
H0084	001	0	1	04	01	H0084_001_0	10	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
H0084	001	0	1	04	01	H0084_001_0	10	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
H0084	001	0	1	04	01	H0084_001_0	10	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
H0084	001	0	1	04	01	H0084_001_0	10	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	39.00	117.00								39.00		39.00	97.50								39.00			
H0104	002	0	1	04	01	H0104_002_0	5	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	180.00								60.00		60.00	180.00								60.00			
H0104	002	0	1	04	01	H0104_002_0	5	5	4	1	Tier 5	100000	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H0104	002	0	1	04	01	H0104_002_0	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	9.00								3.00			
H0104	002	0	1	04	01	H0104_002_0	5	2	4	1	Tier 2	000100	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	6.00	18.00								6.00		6.00	18.00								6.00			
H0104	002	0	1	04	01	H0104_002_0	5	3	4	1	Tier 3	000010	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00								35.00		35.00	105.00								35.00			
H0104	004	0	1	04	01	H0104_004_0	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	9.00								3.00			
H0104	004	0	1	04	01	H0104_004_0	5	3	4	3	Tier 3	000010	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H0104	004	0	1	04	01	H0104_004_0	5	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H0104	004	0	1	04	01	H0104_004_0	5	5	4	3	Tier 5	100000	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
H0104	004	0	1	04	01	H0104_004_0	5	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H0104	004	0	1	04	01	H0104_004_0	5	3	4	1	Tier 3	000010	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00								35.00		35.00	105.00								35.00			
H0104	004	0	1	04	01	H0104_004_0	5	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	180.00								60.00		60.00	180.00								60.00			
H0104	004	0	1	04	01	H0104_004_0	5	5	4	1	Tier 5	100000	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H0104	004	0	1	04	01	H0104_004_0	5	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	9.00								3.00	1	1	
H0104	004	0	1	04	01	H0104_004_0	5	2	4	1	Tier 2	000100	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	6.00	18.00								6.00		6.00	18.00								6.00			
H0104	008	0	1	04	01	H0104_008_0	6	3	4	1	Tier 3	000010	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00								40.00		40.00	120.00								40.00			
H0104	008	0	1	04	01	H0104_008_0	6	2	4	1	Tier 2	000100	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	7.00	21.00								7.00		7.00	21.00								7.00			
H0104	008	0	1	04	01	H0104_008_0	6	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00		4.00	12.00								4.00			
H0104	008	0	1	04	01	H0104_008_0	6	5	4	3	Tier 5	100000	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
H0104	008	0	1	04	01	H0104_008_0	6	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H0104	008	0	1	04	01	H0104_008_0	6	3	4	3	Tier 3	000010	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H0104	008	0	1	04	01	H0104_008_0	6	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H0104	008	0	1	04	01	H0104_008_0	6	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
H0104	008	0	1	04	01	H0104_008_0	6	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	180.00								60.00		60.00	180.00								60.00			
H0104	008	0	1	04	01	H0104_008_0	6	5	4	1	Tier 5	100000	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H0108	004	0	1	01	01	H0108_004_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H0108	004	0	1	01	01	H0108_004_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0108	004	0	1	01	01	H0108_004_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00	1	2	10000000
H0108	004	0	1	01	01	H0108_004_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10001000
H0108	004	0	1	01	01	H0108_004_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H0108	004	0	1	01	01	H0108_004_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0108	004	0	1	01	01	H0108_004_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00			
H0108	004	0	1	01	01	H0108_004_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H0108	005	0	1	01	01	H0108_005_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H0108	005	0	1	01	01	H0108_005_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0108	005	0	1	01	01	H0108_005_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0108	005	0	1	01	01	H0108_005_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0108	005	0	1	01	01	H0108_005_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H0108	005	0	1	01	01	H0108_005_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0108	005	0	1	01	01	H0108_005_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0108	005	0	1	01	01	H0108_005_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0108	006	0	1	02	01	H0108_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0108	006	0	1	02	01	H0108_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0108	006	0	1	02	01	H0108_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H0108	006	0	1	02	01	H0108_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0108	006	0	1	02	01	H0108_006_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0108	006	0	1	02	01	H0108_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0108	006	0	1	02	01	H0108_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H0108	006	0	1	02	01	H0108_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0117	005	0	1	01	01	H0117_005_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0117	005	0	1	01	01	H0117_005_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H0117	005	0	1	01	01	H0117_005_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H0117	007	0	1	01	01	H0117_007_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0117	007	0	1	01	01	H0117_007_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H0117	007	0	1	01	01	H0117_007_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
H0117	007	0	1	01	01	H0117_007_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H0141	001	0	1	01	01	H0141_001_0	8	1	4	1	Tier 1	011000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H0141	001	0	1	01	01	H0141_001_0	8	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	2	Tier 4																						Tier 4	98.00	294.00								98.00			294.00								98.00			
H0141	001	0	1	01	01	H0141_001_0	8	3	4	1	Tier 3	010010	1	1	2	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	1	Tier 3	25	25								25			25								25	Tier 3																								
H0141	001	0	1	01	01	H0141_001_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			135.00								45.00			
H0150	001	0	1	01	01	H0150_001_0	7	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0150	001	0	1	01	01	H0150_001_0	7	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0150	001	0	1	01	01	H0150_001_0	7	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0150	001	0	1	01	01	H0150_001_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H0150	001	0	1	01	01	H0150_001_0	7	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00			45.00								15.00	1	1	
H0150	001	0	1	01	01	H0150_001_0	7	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H0150	001	0	1	01	01	H0150_001_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H0150	001	0	1	01	01	H0150_001_0	7	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00			45.00								15.00			
H0150	001	0	1	01	01	H0150_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H0150	001	0	1	01	01	H0150_001_0	7	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H0150	019	0	1	01	01	H0150_019_0	8	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0150	019	0	1	01	01	H0150_019_0	8	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0150	019	0	1	01	01	H0150_019_0	8	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0150	019	0	1	01	01	H0150_019_0	8	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	2	01000000
H0150	019	0	1	01	01	H0150_019_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H0150	019	0	1	01	01	H0150_019_0	8	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H0150	019	0	1	01	01	H0150_019_0	8	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																								
H0150	019	0	1	01	01	H0150_019_0	8	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H0150	019	0	1	01	01	H0150_019_0	8	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H0150	019	0	1	01	01	H0150_019_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H0150	021	0	1	01	01	H0150_021_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H0150	021	0	1	01	01	H0150_021_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0150	021	0	1	01	01	H0150_021_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0150	021	0	1	01	01	H0150_021_0	6	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0150	021	0	1	01	01	H0150_021_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	1	
H0150	021	0	1	01	01	H0150_021_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H0150	021	0	1	01	01	H0150_021_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H0150	021	0	1	01	01	H0150_021_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	6	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00			
H0150	021	0	1	01	01	H0150_021_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H0151	001	0	1	01	01	H0151_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	4.00	12.00								4.00						8.00			12.00		4.00			
H0151	001	0	1	01	01	H0151_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0151	001	0	1	01	01	H0151_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0151	001	0	1	01	01	H0151_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0151	023	0	1	01	01	H0151_023_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0151	023	0	1	01	01	H0151_023_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0151	023	0	1	01	01	H0151_023_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0151	023	0	1	01	01	H0151_023_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0154	001	0	1	01	01	H0154_001_0	5	1	3	1	Tier 1	010000		2	2	Tier 1	111000000010000010010	31	90								31						90			90		31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00						12.50			15.00		5.00			
H0154	001	0	1	01	01	H0154_001_0	5	2	3	1	Tier 2	000001		2	2	Tier 2	111000000010000010010	31	90								31						90			90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00						75.00			90.00		30.00			
H0154	001	0	1	01	01	H0154_001_0	5	4	3	1	Tier 4	010010		1	2	Tier 4	110000000010000000000	31									31											31		Tier 4	1	Tier 4	26									26											26	Tier 4																								
H0154	001	0	1	01	01	H0154_001_0	5	3	3	1	Tier 3	100000		2	1	Tier 3	111000000010000010010	31	90								31						90			90		31	1	Tier 3	2	Tier 3																						Tier 3	55.00	165.00								55.00						137.50			165.00		55.00			
H0154	011	0	1	01	01	H0154_011_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010000010010	31	90								31						90			90		31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00						12.50			15.00		5.00			
H0154	011	0	1	01	01	H0154_011_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010000010010	31	90								31						90			90		31	1	Tier 3	2	Tier 3																						Tier 3	55.00	165.00								55.00						137.50			165.00		55.00			
H0154	011	0	1	01	01	H0154_011_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010000010010	31	90								31						90			90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00						75.00			90.00		30.00			
H0154	011	0	1	01	01	H0154_011_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000010000000000	31									31											31		Tier 4	1	Tier 4	33									33											33	Tier 4																								
H0154	011	0	1	01	01	H0154_011_0	5	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010000010010	31	90								31						90			90		31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00						12.50			15.00		5.00	1	1	
H0154	011	0	1	01	01	H0154_011_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H0154	011	0	1	01	01	H0154_011_0	5	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H0154	011	0	1	01	01	H0154_011_0	5	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H0154	013	0	1	01	01	H0154_013_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000010000000000	31									31											31		Tier 4	1	Tier 4	33									33											33	Tier 4																								
H0154	013	0	1	01	01	H0154_013_0	4	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H0154	013	0	1	01	01	H0154_013_0	4	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010000010010	31	90								31						90			90		31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00						12.50			15.00		5.00	1	1	
H0154	013	0	1	01	01	H0154_013_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H0154	013	0	1	01	01	H0154_013_0	4	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H0154	013	0	1	01	01	H0154_013_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010000010010	31	90								31						90			90		31	1	Tier 3	2	Tier 3																						Tier 3	55.00	165.00								55.00						137.50			165.00		55.00			
H0154	013	0	1	01	01	H0154_013_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010000010010	31	90								31						90			90		31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00						12.50			15.00		5.00			
H0154	013	0	1	01	01	H0154_013_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010000010010	31	90								31						90			90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00						75.00			90.00		30.00			
H0248	001	0	1	04	01	H0248_001_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H0248	001	0	1	04	01	H0248_001_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0248	001	0	1	04	01	H0248_001_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0248	001	0	1	04	01	H0248_001_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0248	001	0	1	04	01	H0248_001_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0248	001	0	1	04	01	H0248_001_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0248	001	0	1	04	01	H0248_001_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0248	002	0	1	04	01	H0248_002_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0248	002	0	1	04	01	H0248_002_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0248	002	0	1	04	01	H0248_002_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0248	002	0	1	04	01	H0248_002_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H0248	002	0	1	04	01	H0248_002_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0248	002	0	1	04	01	H0248_002_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0248	002	0	1	04	01	H0248_002_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H0248	002	0	1	04	01	H0248_002_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0302	001	0	1	01	01	H0302_001_0	7	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0302	001	0	1	01	01	H0302_001_0	7	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0302	001	0	1	01	01	H0302_001_0	7	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0302	001	0	1	01	01	H0302_001_0	7	1	4	1	Value Generic	010000	1	2	2	Value Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	11.00	7.50							4.00			
H0302	001	0	1	01	01	H0302_001_0	7	2	4	1	Generic	010000	3	2	2	Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Generic	2	Generic																						Generic	12.00	36.00	24.00							12.00		12.00	33.00	22.00							12.00			
H0302	001	0	1	01	01	H0302_001_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	96.00	64.00							35.00			
H0302	001	0	1	01	01	H0302_001_0	7	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	165.00	110.00							60.00			
H0302	001	0	1	01	01	H0302_001_0	7	5	4	1	Specialty	010010	1	1	2	Specialty	111100000010111000000	30	90	60							30		30	90	60							31	1	Specialty	1	Specialty	25	25	25							25		25	25	25							25	Specialty																								
H0302	001	0	1	01	01	H0302_001_0	7	1	4	3	Value Generic	010000	1	2	2	Value Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Value Generic	2	Value Generic																						Value Generic	8.00	24.00	16.00							8.00		8.00	22.00	15.00							8.00	1	1	
H0302	001	0	1	01	01	H0302_001_0	7	2	4	3	Generic	010000	3	2	2	Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Generic	2	Generic																						Generic	24.00	72.00	48.00							24.00		24.00	66.00	44.00							24.00	1	1	
H0302	004	0	1	01	01	H0302_004_0	6	1	4	1	Value Generic	010000	1	2	2	Value Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	11.00	7.50							4.00			
H0302	004	0	1	01	01	H0302_004_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0302	004	0	1	01	01	H0302_004_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0302	004	0	1	01	01	H0302_004_0	6	2	4	3	Generic	010000	3	2	2	Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Generic	2	Generic																						Generic	24.00	72.00	48.00							24.00		24.00	66.00	44.00							24.00	1	1	
H0302	004	0	1	01	01	H0302_004_0	6	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0302	004	0	1	01	01	H0302_004_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	111100000010111000000	30	90	60							30		30	90	60							31	1	Specialty	1	Specialty	25	25	25							25		25	25	25							25	Specialty																								
H0302	004	0	1	01	01	H0302_004_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	165.00	110.00							60.00			
H0302	004	0	1	01	01	H0302_004_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	96.00	64.00							35.00			
H0302	004	0	1	01	01	H0302_004_0	6	2	4	1	Generic	010000	3	2	2	Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Generic	2	Generic																						Generic	12.00	36.00	24.00							12.00		12.00	33.00	22.00							12.00			
H0302	004	0	1	01	01	H0302_004_0	6	1	4	3	Value Generic	010000	1	2	2	Value Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Value Generic	2	Value Generic																						Value Generic	8.00	24.00	16.00							8.00		8.00	22.00	15.00							8.00	1	1	
H0302	007	0	1	01	01	H0302_007_0	6	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0302	007	0	1	01	01	H0302_007_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0302	007	0	1	01	01	H0302_007_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0302	007	0	1	01	01	H0302_007_0	6	2	4	3	Generic	010000	3	2	2	Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Generic	2	Generic																						Generic	24.00	72.00	48.00							24.00		24.00	66.00	44.00							24.00	1	1	
H0302	007	0	1	01	01	H0302_007_0	6	1	4	3	Value Generic	010000	1	2	2	Value Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Value Generic	2	Value Generic																						Value Generic	8.00	24.00	16.00							8.00		8.00	22.00	15.00							8.00	1	1	
H0302	007	0	1	01	01	H0302_007_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	111100000010111000000	30	90	60							30		30	90	60							31	1	Specialty	1	Specialty	25	25	25							25		25	25	25							25	Specialty																								
H0302	007	0	1	01	01	H0302_007_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00	120.00							60.00		60.00	165.00	110.00							60.00			
H0302	007	0	1	01	01	H0302_007_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	96.00	64.00							35.00			
H0302	007	0	1	01	01	H0302_007_0	6	1	4	1	Value Generic	010000	1	2	2	Value Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	11.00	7.50							4.00			
H0302	007	0	1	01	01	H0302_007_0	6	2	4	1	Generic	010000	3	2	2	Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Generic	2	Generic																						Generic	12.00	36.00	24.00							12.00		12.00	33.00	22.00							12.00			
H0303	013	0	1	01	01	H0303_013_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0303	013	0	1	01	01	H0303_013_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0303	013	0	1	01	01	H0303_013_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0303	013	0	1	01	01	H0303_013_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0303	015	0	1	01	01	H0303_015_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0303	015	0	1	01	01	H0303_015_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0303	015	0	1	01	01	H0303_015_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0303	015	0	1	01	01	H0303_015_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0303	039	0	1	01	01	H0303_039_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	82.00	246.00								82.00						236.00			246.00		82.00			
H0303	039	0	1	01	01	H0303_039_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0303	039	0	1	01	01	H0303_039_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0303	039	0	1	01	01	H0303_039_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0307	008	0	1	01	01	H0307_008_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0307	008	0	1	01	01	H0307_008_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0307	008	0	1	01	01	H0307_008_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0307	008	0	1	01	01	H0307_008_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0307	008	0	1	01	01	H0307_008_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0307	008	0	1	01	01	H0307_008_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0307	008	0	1	01	01	H0307_008_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0307	008	0	1	01	01	H0307_008_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H0307	009	0	1	02	01	H0307_009_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0307	009	0	1	02	01	H0307_009_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0307	009	0	1	02	01	H0307_009_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H0307	009	0	1	02	01	H0307_009_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0307	009	0	1	02	01	H0307_009_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0307	009	0	1	02	01	H0307_009_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0307	009	0	1	02	01	H0307_009_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0307	009	0	1	02	01	H0307_009_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0307	010	0	1	02	01	H0307_010_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H0307	010	0	1	02	01	H0307_010_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0307	010	0	1	02	01	H0307_010_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0307	010	0	1	02	01	H0307_010_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0307	010	0	1	02	01	H0307_010_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0307	010	0	1	02	01	H0307_010_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0307	010	0	1	02	01	H0307_010_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0307	010	0	1	02	01	H0307_010_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0316	002	0	1	01	01	H0316_002_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0316	002	0	1	01	01	H0316_002_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0316	002	0	1	01	01	H0316_002_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0316	002	0	1	01	01	H0316_002_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0316	013	0	1	01	01	H0316_013_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0316	013	0	1	01	01	H0316_013_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0316	013	0	1	01	01	H0316_013_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0316	013	0	1	01	01	H0316_013_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0316	014	0	1	02	01	H0316_014_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0316	014	0	1	02	01	H0316_014_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0316	014	0	1	02	01	H0316_014_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0316	014	0	1	02	01	H0316_014_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0317	001	0	1	04	01	H0317_001_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0317	001	0	1	04	01	H0317_001_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0317	001	0	1	04	01	H0317_001_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H0317	001	0	1	04	01	H0317_001_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0317	001	0	1	04	01	H0317_001_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0317	001	0	1	04	01	H0317_001_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0317	001	0	1	04	01	H0317_001_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0317	001	0	1	04	01	H0317_001_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0317	002	0	1	04	01	H0317_002_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0317	002	0	1	04	01	H0317_002_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0317	002	0	1	04	01	H0317_002_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0317	002	0	1	04	01	H0317_002_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0317	002	0	1	04	01	H0317_002_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0317	002	0	1	04	01	H0317_002_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0317	002	0	1	04	01	H0317_002_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0317	004	0	1	04	01	H0317_004_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0317	004	0	1	04	01	H0317_004_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0317	004	0	1	04	01	H0317_004_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0317	004	0	1	04	01	H0317_004_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0317	004	0	1	04	01	H0317_004_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0317	004	0	1	04	01	H0317_004_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H0317	004	0	1	04	01	H0317_004_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0317	004	0	1	04	01	H0317_004_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0317	006	0	1	04	01	H0317_006_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0317	006	0	1	04	01	H0317_006_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H0317	006	0	1	04	01	H0317_006_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0317	006	0	1	04	01	H0317_006_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0317	006	0	1	04	01	H0317_006_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0317	006	0	1	04	01	H0317_006_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H0317	006	0	1	04	01	H0317_006_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H0317	006	0	1	04	01	H0317_006_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0318	002	0	1	01	01	H0318_002_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H0318	002	0	1	01	01	H0318_002_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H0318	002	0	1	01	01	H0318_002_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H0318	002	0	1	01	01	H0318_002_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0319	004	0	1	04	01	H0319_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0319	004	0	1	04	01	H0319_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0319	004	0	1	04	01	H0319_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0320	001	0	1	01	01	H0320_001_0	10	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H0320	001	0	1	01	01	H0320_001_0	10	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	20.00	60.00								20.00			40.00								20.00			
H0320	001	0	1	01	01	H0320_001_0	10	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H0320	001	0	1	01	01	H0320_001_0	10	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H0320	001	0	1	01	01	H0320_001_0	10	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H0320	005	0	1	01	01	H0320_005_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H0320	005	0	1	01	01	H0320_005_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0320	005	0	1	01	01	H0320_005_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H0320	005	0	1	01	01	H0320_005_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H0320	005	0	1	01	01	H0320_005_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H0320	005	0	1	01	01	H0320_005_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	20.00	60.00								20.00			40.00								20.00			
H0320	005	0	1	01	01	H0320_005_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H0320	005	0	1	01	01	H0320_005_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0320	005	0	1	01	01	H0320_005_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0320	005	0	1	01	01	H0320_005_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																						2		
H0320	006	0	1	01	01	H0320_006_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H0320	006	0	1	01	01	H0320_006_0	5	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H0320	006	0	1	01	01	H0320_006_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H0320	006	0	1	01	01	H0320_006_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H0320	006	0	1	01	01	H0320_006_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	20.00	60.00								20.00			40.00								20.00			
H0320	007	0	1	02	01	H0320_007_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H0320	007	0	1	02	01	H0320_007_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H0320	007	0	1	02	01	H0320_007_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H0320	007	0	1	02	01	H0320_007_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H0320	007	0	1	02	01	H0320_007_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H0320	007	0	1	02	01	H0320_007_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0320	007	0	1	02	01	H0320_007_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H0320	007	0	1	02	01	H0320_007_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0320	007	0	1	02	01	H0320_007_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0320	007	0	1	02	01	H0320_007_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																						2		
H0332	002	0	1	01	01	H0332_002_0	6	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred 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	6	2	4	1	Non-Preferred Generic/Preferred Brand	000101	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	6	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0332	002	0	1	01	01	H0332_002_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0332	002	0	1	01	01	H0332_002_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000101	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H0332	002	0	1	01	01	H0332_002_0	6	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00	1	1	
H0332	002	0	1	01	01	H0332_002_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	1	Specialty	1	Specialty				30	30		30	30		30		30	30								30	Specialty																								
H0332	002	0	1	01	01	H0332_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Non-Preferred Brand	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	5	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred 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	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0332	004	0	1	02	01	H0332_004_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000101	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H0332	004	0	1	02	01	H0332_004_0	5	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00	0.00		5.00	15.00		5.00		0.00	0.00								5.00	1	1	
H0332	004	0	1	02	01	H0332_004_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	1	Specialty	1	Specialty				30	30		30	30		30		30	30								30	Specialty																								
H0332	004	0	1	02	01	H0332_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Non-Preferred Brand	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	5	2	4	1	Non-Preferred Generic/Preferred Brand	000101	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0351	014	0	1	01	01	H0351_014_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0351	014	0	1	01	01	H0351_014_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0351	014	0	1	01	01	H0351_014_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0351	014	0	1	01	01	H0351_014_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	6.00	18.00	12.00							6.00					6.00	12.00	12.00	6.00	18.00	12.00	6.00			
H0351	014	0	1	01	01	H0351_014_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0351	029	0	1	01	01	H0351_029_0	4	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00	4.00							2.00					2.00	4.00	4.00	2.00	6.00	4.00	2.00			
H0351	029	0	1	01	01	H0351_029_0	4	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	32.00	96.00	64.00							32.00					32.00	64.00	64.00	32.00	96.00	64.00	32.00			
H0351	029	0	1	01	01	H0351_029_0	4	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	75.00	225.00	150.00							75.00					75.00	188.00	150.00	75.00	225.00	150.00	75.00			
H0351	029	0	1	01	01	H0351_029_0	4	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
H0351	029	0	1	01	01	H0351_029_0	4	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
H0351	034	0	1	01	01	H0351_034_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0351	034	0	1	01	01	H0351_034_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0351	034	0	1	01	01	H0351_034_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0351	034	0	1	01	01	H0351_034_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0351	034	0	1	01	01	H0351_034_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0351	035	0	1	01	01	H0351_035_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	82.00	246.00	164.00							82.00					82.00	205.00	164.00	82.00	246.00	164.00	82.00			
H0351	035	0	1	01	01	H0351_035_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0351	035	0	1	01	01	H0351_035_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0351	035	0	1	01	01	H0351_035_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0351	035	0	1	01	01	H0351_035_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00	82.00							41.00					41.00	82.00	82.00	41.00	123.00	82.00	41.00			
H0351	036	0	1	01	01	H0351_036_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0351	036	0	1	01	01	H0351_036_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0351	036	0	1	01	01	H0351_036_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00	82.00							41.00					41.00	82.00	82.00	41.00	123.00	82.00	41.00			
H0351	036	0	1	01	01	H0351_036_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	82.00	246.00	164.00							82.00					82.00	205.00	164.00	82.00	246.00	164.00	82.00			
H0351	036	0	1	01	01	H0351_036_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0354	001	0	1	01	01	H0354_001_0	9	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00		65.00	195.00								65.00			
H0354	001	0	1	01	01	H0354_001_0	9	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00		40.00	120.00								40.00			
H0354	001	0	1	01	01	H0354_001_0	9	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	15.00								5.00			
H0354	001	0	1	01	01	H0354_001_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	65.00	195.00								65.00		65.00	195.00								65.00			
H0354	001	0	1	01	01	H0354_001_0	9	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H0354	001	0	1	01	01	H0354_001_0	9	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H0354	001	0	1	01	01	H0354_001_0	9	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H0354	001	0	1	01	01	H0354_001_0	9	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H0370	001	0	1	04	01	H0370_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H0370	001	0	1	04	01	H0370_001_0	7	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H0370	001	0	1	04	01	H0370_001_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	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	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H0401	002	0	1	02	01	H0401_002_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0401	002	0	1	02	01	H0401_002_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0401	002	0	1	02	01	H0401_002_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0401	002	0	1	02	01	H0401_002_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						0.00			18.00		6.00			
H0410	001	0	1	37	05	H0410_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0410	001	0	1	37	05	H0410_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H0410	001	0	1	37	05	H0410_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H0410	001	0	1	37	05	H0410_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0410	003	0	1	37	05	H0410_003_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H0410	003	0	1	37	05	H0410_003_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H0410	003	0	1	37	05	H0410_003_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0410	003	0	1	37	05	H0410_003_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0410	004	0	1	37	05	H0410_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H0410	004	0	1	37	05	H0410_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0410	004	0	1	37	05	H0410_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H0410	004	0	1	37	05	H0410_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0474	001	0	1	01	01	H0474_001_0	6	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H0474	001	0	1	01	01	H0474_001_0	6	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H0474	001	0	1	01	01	H0474_001_0	6	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	59.00	118.00									59.00	59.00	118.00								59.00			
H0474	001	0	1	01	01	H0474_001_0	6	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H0474	002	0	1	01	01	H0474_002_0	5	2	4	3	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0474	002	0	1	01	01	H0474_002_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																						2		
H0474	002	0	1	01	01	H0474_002_0	5	4	4	3	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0474	002	0	1	01	01	H0474_002_0	5	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H0474	002	0	1	01	01	H0474_002_0	5	1	4	3	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00	1	1	
H0474	002	0	1	01	01	H0474_002_0	5	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00			
H0474	002	0	1	01	01	H0474_002_0	5	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	20.00	40.00									20.00	20.00	40.00								20.00			
H0474	002	0	1	01	01	H0474_002_0	5	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	50.00	100.00									50.00	50.00	100.00								50.00			
H0490	001	0	1	01	01	H0490_001_0	6	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H0490	001	0	1	01	01	H0490_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H0490	001	0	1	01	01	H0490_001_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H0490	004	0	1	01	01	H0490_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	88.00	264.00								88.00			264.00								88.00			
H0490	004	0	1	01	01	H0490_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	44.00	132.00								44.00			132.00								44.00			
H0490	004	0	1	01	01	H0490_004_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H0490	004	0	1	01	01	H0490_004_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H0504	015	0	1	01	01	H0504_015_0	4	4	4	1	Injectables	010010	1	2	1	Injectables	100011011010010000000				30	90		30	90		30			90								34	1	Injectables	1	Injectables				33	33		33	33		33			33								33	Injectables																								
H0504	015	0	1	01	01	H0504_015_0	4	3	4	1	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				68.00	136.00		68.00	204.00		68.00			136.00								68.00			
H0504	015	0	1	01	01	H0504_015_0	4	2	4	1	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	2	Formulary Brand																						Formulary Brand				35.00	70.00		35.00	105.00		35.00			70.00								35.00			
H0504	015	0	1	01	01	H0504_015_0	4	1	4	1	Formulary Generic	010010	3	2	2	Formulary Generic	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic	2	Formulary Generic																						Formulary Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00			
H0504	015	0	1	01	01	H0504_015_0	4	5	4	1	Formulary Specialty (Unique High Cost Drugs)	010010	1	1	2	Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Specialty (Unique High Cost Drugs)	1	Formulary Specialty (Unique High Cost Drugs)				33	33		33	33		33			33								33	Formulary Specialty (Unique High Cost Drugs)																								
H0504	015	0	1	01	01	H0504_015_0	4	4	4	3	Injectables	010010	1	2	1	Injectables																								Injectables		Injectables																						Injectables																						2		
H0504	015	0	1	01	01	H0504_015_0	4	3	4	3	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0504	015	0	1	01	01	H0504_015_0	4	2	4	3	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	1	Formulary Brand				50	50		55	55		50			50								50	Formulary Brand																						1	1	
H0504	015	0	1	01	01	H0504_015_0	4	1	4	3	Formulary Generic	010010	3	2	2	Formulary Generic	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic	2	Formulary Generic																						Formulary Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00	1	1	
H0504	015	0	1	01	01	H0504_015_0	4	5	4	3	Formulary Specialty (Unique High Cost Drugs)	010010	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)																						2		
H0504	017	0	1	01	01	H0504_017_0	5	4	4	1	Injectables	010010	1	2	1	Injectables	100011011010010000000				30	90		30	90		30			90								34	1	Injectables	1	Injectables				33	33		33	33		33			33								33	Injectables																								
H0504	017	0	1	01	01	H0504_017_0	5	3	4	1	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				68.00	136.00		68.00	204.00		68.00			136.00								68.00			
H0504	017	0	1	01	01	H0504_017_0	5	2	4	1	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	2	Formulary Brand																						Formulary Brand				35.00	70.00		35.00	105.00		35.00			70.00								35.00			
H0504	017	0	1	01	01	H0504_017_0	5	1	4	1	Formulary Generic	010010	3	2	2	Formulary Generic	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic	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	5	1	4	3	Formulary Generic	010010	3	2	2	Formulary Generic	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic	2	Formulary Generic																						Formulary Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00	1	1	
H0504	017	0	1	01	01	H0504_017_0	5	2	4	3	Formulary Brand	010010	1	2	2	Formulary Brand																								Formulary Brand		Formulary Brand																						Formulary Brand																						2		
H0504	017	0	1	01	01	H0504_017_0	5	3	4	3	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0504	017	0	1	01	01	H0504_017_0	5	5	4	1	Formulary Specialty (Unique High Cost Drugs)	010010	1	1	2	Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Specialty (Unique High Cost Drugs)	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	5	5	4	3	Formulary Specialty (Unique High Cost Drugs)	010010	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)																						2		
H0504	017	0	1	01	01	H0504_017_0	5	4	4	3	Injectables	010010	1	2	1	Injectables																								Injectables		Injectables																						Injectables																						2		
H0504	021	0	1	01	01	H0504_021_0	7	4	4	3	Injectables	010010	1	2	1	Injectables																								Injectables		Injectables																						Injectables																						2		
H0504	021	0	1	01	01	H0504_021_0	7	5	4	3	Formulary Specialty (Unique High Cost Drugs)	010010	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)																						2		
H0504	021	0	1	01	01	H0504_021_0	7	3	4	3	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0504	021	0	1	01	01	H0504_021_0	7	2	4	3	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	2	Formulary Brand																						Formulary Brand				20.00	40.00		20.00	60.00		20.00			40.00								20.00	1	1	
H0504	021	0	1	01	01	H0504_021_0	7	1	4	3	Formulary Generic and Insulin	010010	3	2	2	Formulary Generic and Insulin	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic and Insulin	2	Formulary Generic and Insulin																						Formulary Generic and Insulin				0.00	0.00		0.00	0.00		0.00			0.00								0.00	1	1	
H0504	021	0	1	01	01	H0504_021_0	7	1	4	1	Formulary Generic and Insulin	010010	3	2	2	Formulary Generic and Insulin	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic and Insulin	2	Formulary Generic and Insulin																						Formulary Generic and Insulin				0.00	0.00		0.00	0.00		0.00			0.00								0.00			
H0504	021	0	1	01	01	H0504_021_0	7	2	4	1	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	2	Formulary Brand																						Formulary Brand				20.00	40.00		20.00	60.00		20.00			40.00								20.00			
H0504	021	0	1	01	01	H0504_021_0	7	3	4	1	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								34	1	Non-Preferred Brand	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	7	4	4	1	Injectables	010010	1	2	1	Injectables	100011011010010000000				30	90		30	90		30			90								34	1	Injectables	1	Injectables				33	33		33	33		33			33								33	Injectables																								
H0504	021	0	1	01	01	H0504_021_0	7	5	4	1	Formulary Specialty (Unique High Cost Drugs)	010010	1	1	2	Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Specialty (Unique High Cost Drugs)	1	Formulary Specialty (Unique High Cost Drugs)				33	33		33	33		33			33								33	Formulary Specialty (Unique High Cost Drugs)																								
H0504	026	0	1	01	01	H0504_026_0	5	1	4	1	Formulary Generic	010010	3	2	2	Formulary Generic	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic	2	Formulary Generic																						Formulary Generic				6.00	12.00		6.00	18.00		6.00			12.00								6.00			
H0504	026	0	1	01	01	H0504_026_0	5	2	4	1	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	2	Formulary Brand																						Formulary Brand				40.00	80.00		40.00	120.00		40.00			80.00								40.00			
H0504	026	0	1	01	01	H0504_026_0	5	3	4	1	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	150.00		75.00	225.00		75.00			150.00								75.00			
H0504	026	0	1	01	01	H0504_026_0	5	4	4	1	Injectables	010010	1	2	1	Injectables	100011011010010000000				30	90		30	90		30			90								34	1	Injectables	1	Injectables				33	33		33	33		33			33								33	Injectables																								
H0504	026	0	1	01	01	H0504_026_0	5	5	4	1	Formulary Specialty (Unique High Cost Drugs)	010010	1	1	2	Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Specialty (Unique High Cost Drugs)	1	Formulary Specialty (Unique High Cost Drugs)				25	25		25	25		25			25								25	Formulary Specialty (Unique High Cost Drugs)																								
H0523	002	0	1	01	01	H0523_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																						2		
H0523	002	0	1	01	01	H0523_002_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0523	002	0	1	01	01	H0523_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																						2		
H0523	002	0	1	01	01	H0523_002_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0523	002	0	1	01	01	H0523_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H0523	002	0	1	01	01	H0523_002_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H0523	002	0	1	01	01	H0523_002_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H0523	002	0	1	01	01	H0523_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H0523	002	0	1	01	01	H0523_002_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0523	002	0	1	01	01	H0523_002_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H0523	022	0	1	01	01	H0523_022_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0523	022	0	1	01	01	H0523_022_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0523	022	0	1	01	01	H0523_022_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																						2		
H0523	022	0	1	01	01	H0523_022_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0523	022	0	1	01	01	H0523_022_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H0523	022	0	1	01	01	H0523_022_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H0523	022	0	1	01	01	H0523_022_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H0523	022	0	1	01	01	H0523_022_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H0523	022	0	1	01	01	H0523_022_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0523	022	0	1	01	01	H0523_022_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H0523	031	0	1	01	01	H0523_031_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H0523	031	0	1	01	01	H0523_031_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					74.00			111.00		37.00			
H0523	031	0	1	01	01	H0523_031_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H0523	031	0	1	01	01	H0523_031_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H0523	031	0	1	01	01	H0523_031_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H0523	032	0	1	01	01	H0523_032_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0523	032	0	1	01	01	H0523_032_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																						2		
H0523	032	0	1	01	01	H0523_032_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0523	032	0	1	01	01	H0523_032_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0523	032	0	1	01	01	H0523_032_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H0523	032	0	1	01	01	H0523_032_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H0523	032	0	1	01	01	H0523_032_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0523	032	0	1	01	01	H0523_032_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H0523	032	0	1	01	01	H0523_032_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	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	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H0523	051	0	1	01	01	H0523_051_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0523	051	0	1	01	01	H0523_051_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H0523	051	0	1	01	01	H0523_051_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H0523	051	0	1	01	01	H0523_051_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H0523	051	0	1	01	01	H0523_051_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H0523	051	0	1	01	01	H0523_051_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0523	051	0	1	01	01	H0523_051_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																						2		
H0523	051	0	1	01	01	H0523_051_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0523	051	0	1	01	01	H0523_051_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0523	051	0	1	01	01	H0523_051_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H0523	052	0	1	01	01	H0523_052_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H0523	052	0	1	01	01	H0523_052_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H0523	052	0	1	01	01	H0523_052_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0523	052	0	1	01	01	H0523_052_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H0523	052	0	1	01	01	H0523_052_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H0523	054	0	1	01	01	H0523_054_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H0523	054	0	1	01	01	H0523_054_0	4	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0523	054	0	1	01	01	H0523_054_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																						2		
H0523	054	0	1	01	01	H0523_054_0	4	4	4	3	Tier 4 - Non-Preferred Generic	000100	1	2	1	Tier 4 - Non-Preferred Generic																								Tier 4 - Non-Preferred Generic		Tier 4 - Non-Preferred Generic																						Tier 4 - Non-Preferred Generic																						2		
H0523	054	0	1	01	01	H0523_054_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H0523	054	0	1	01	01	H0523_054_0	4	4	4	1	Tier 4 - Non-Preferred Generic	000100	1	2	1	Tier 4 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Generic	2	Tier 4 - Non-Preferred Generic																						Tier 4 - Non-Preferred Generic	80.00	240.00									80.00					160.00			240.00		80.00			
H0523	054	0	1	01	01	H0523_054_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0523	054	0	1	01	01	H0523_054_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H0523	054	0	1	01	01	H0523_054_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H0523	054	0	1	01	01	H0523_054_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H0524	002	0	2	01	01	H0524_002_0	8	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	002	0	2	01	01	H0524_002_0	8	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	8.00		24.00							8.00		8.00		16.00							8.00	1	1	
H0524	002	0	2	01	01	H0524_002_0	8	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	002	0	2	01	01	H0524_002_0	8	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	002	0	2	01	01	H0524_002_0	8	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	8.00		24.00							8.00		8.00		16.00							8.00			
H0524	002	0	2	01	01	H0524_002_0	8	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	003	0	1	01	01	H0524_003_0	6	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	003	0	1	01	01	H0524_003_0	6	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	003	0	1	01	01	H0524_003_0	6	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	003	0	1	01	01	H0524_003_0	6	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00	1	1	
H0524	003	0	1	01	01	H0524_003_0	6	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00			
H0524	003	0	1	01	01	H0524_003_0	6	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00			
H0524	008	0	1	01	01	H0524_008_0	6	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	008	0	1	01	01	H0524_008_0	6	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	008	0	1	01	01	H0524_008_0	6	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	008	0	1	01	01	H0524_008_0	6	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	008	0	1	01	01	H0524_008_0	6	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	008	0	1	01	01	H0524_008_0	6	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	010	0	2	01	01	H0524_010_0	8	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	010	0	2	01	01	H0524_010_0	8	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	010	0	2	01	01	H0524_010_0	8	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	010	0	2	01	01	H0524_010_0	8	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	010	0	2	01	01	H0524_010_0	8	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	010	0	2	01	01	H0524_010_0	8	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	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	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	013	0	1	01	01	H0524_013_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	013	0	1	01	01	H0524_013_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	013	0	1	01	01	H0524_013_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	013	0	1	01	01	H0524_013_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	013	0	1	01	01	H0524_013_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	015	0	1	01	01	H0524_015_0	6	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	015	0	1	01	01	H0524_015_0	6	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	015	0	1	01	01	H0524_015_0	6	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	015	0	1	01	01	H0524_015_0	6	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	015	0	1	01	01	H0524_015_0	6	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	015	0	1	01	01	H0524_015_0	6	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	029	0	1	01	01	H0524_029_0	6	3	3	1	Specialty	000010		1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	029	0	1	01	01	H0524_029_0	6	1	3	1	Generic	010000		2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	12.00		36.00							12.00		12.00		24.00							12.00			
H0524	029	0	1	01	01	H0524_029_0	6	2	3	1	Brand	000010		2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	43.00		129.00							43.00		43.00		86.00							43.00			
H0524	030	0	1	01	01	H0524_030_0	6	3	3	1	Specialty	000010		1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	030	0	1	01	01	H0524_030_0	6	1	3	1	Generic	010000		2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	13.00		39.00							13.00		13.00		26.00							13.00			
H0524	030	0	1	01	01	H0524_030_0	6	2	3	1	Brand	000010		2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	031	0	1	01	01	H0524_031_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	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	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	031	0	1	01	01	H0524_031_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	031	0	1	01	01	H0524_031_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	031	0	1	01	01	H0524_031_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	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	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	032	0	1	01	01	H0524_032_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	032	0	1	01	01	H0524_032_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	032	0	1	01	01	H0524_032_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	032	0	1	01	01	H0524_032_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	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	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	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	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	033	0	1	01	01	H0524_033_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	033	0	1	01	01	H0524_033_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	033	0	1	01	01	H0524_033_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	033	0	1	01	01	H0524_033_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	033	0	1	01	01	H0524_033_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	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	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	034	0	1	01	01	H0524_034_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	034	0	1	01	01	H0524_034_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00	1	1	
H0524	034	0	1	01	01	H0524_034_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	034	0	1	01	01	H0524_034_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	034	0	1	01	01	H0524_034_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	5.00		15.00							5.00		5.00		10.00							5.00			
H0524	034	0	1	01	01	H0524_034_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00			
H0524	035	0	1	01	01	H0524_035_0	7	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	035	0	1	01	01	H0524_035_0	7	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	035	0	1	01	01	H0524_035_0	7	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	035	0	1	01	01	H0524_035_0	7	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	035	0	1	01	01	H0524_035_0	7	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	035	0	1	01	01	H0524_035_0	7	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	036	0	1	01	01	H0524_036_0	7	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	036	0	1	01	01	H0524_036_0	7	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	036	0	1	01	01	H0524_036_0	7	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	036	0	1	01	01	H0524_036_0	7	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	036	0	1	01	01	H0524_036_0	7	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	036	0	1	01	01	H0524_036_0	7	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	037	0	1	01	01	H0524_037_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	037	0	1	01	01	H0524_037_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	037	0	1	01	01	H0524_037_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	037	0	1	01	01	H0524_037_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	037	0	1	01	01	H0524_037_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	037	0	1	01	01	H0524_037_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	038	0	1	01	01	H0524_038_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	038	0	1	01	01	H0524_038_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	038	0	1	01	01	H0524_038_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	038	0	1	01	01	H0524_038_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	038	0	1	01	01	H0524_038_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	038	0	1	01	01	H0524_038_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	039	0	1	01	01	H0524_039_0	5	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	45.00		135.00							45.00		45.00		90.00							45.00			
H0524	039	0	1	01	01	H0524_039_0	5	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	039	0	1	01	01	H0524_039_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	039	0	1	01	01	H0524_039_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	039	0	1	01	01	H0524_039_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	039	0	1	01	01	H0524_039_0	5	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	040	0	1	01	01	H0524_040_0	7	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	7.00		21.00							7.00		7.00		14.00							7.00			
H0524	040	0	1	01	01	H0524_040_0	7	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00			
H0524	040	0	1	01	01	H0524_040_0	7	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	040	0	1	01	01	H0524_040_0	7	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	7.00		21.00							7.00		7.00		14.00							7.00	1	1	
H0524	040	0	1	01	01	H0524_040_0	7	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	040	0	1	01	01	H0524_040_0	7	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0524	041	0	1	01	01	H0524_041_0	7	1	4	1	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00			
H0524	041	0	1	01	01	H0524_041_0	7	2	4	1	Brand	000010	1	2	1	Brand	110100000010101000000	30		100							30		30		100							31	2	Brand	2	Brand																						Brand	35.00		105.00							35.00		35.00		70.00							35.00			
H0524	041	0	1	01	01	H0524_041_0	7	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H0524	041	0	1	01	01	H0524_041_0	7	1	4	3	Generic	010000	1	2	2	Generic	110100000010101000000	30		100							30		30		100							31	2	Generic	2	Generic																						Generic	10.00		30.00							10.00		10.00		20.00							10.00	1	1	
H0524	041	0	1	01	01	H0524_041_0	7	3	4	1	Specialty	000010	1	1	2	Specialty	110100000010101000000	30		100							30		30		100							31	2	Specialty	1	Specialty	25		25							25		25		25							25	Specialty																								
H0524	041	0	1	01	01	H0524_041_0	7	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H0532	001	0	1	01	01	H0532_001_0	4	1	3	1	Tier 1 Generic Drugs	010000		2	2	Tier 1 Generic Drugs	111000000010010000000	34	90								34			90								34	1	Tier 1 Generic Drugs	2	Tier 1 Generic Drugs																						Tier 1 Generic Drugs	10.00	30.00								10.00			30.00								10.00			
H0532	001	0	1	01	01	H0532_001_0	4	4	3	1	Tier 4 Specialty Drugs	000010		1	1	Tier 4 Specialty Drugs	111000000010010000000	34	90								34			90								34	2	Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	33	33								33			33								33	Tier 4 Specialty Drugs																								
H0532	001	0	1	01	01	H0532_001_0	4	3	3	1	Tier 3 Non-Preferred Brand Drugs	100000		2	2	Tier 3 Non-Preferred Brand Drugs	111000000010010000000	34	90								34			90								34	1	Tier 3 Non-Preferred Brand Drugs	2	Tier 3 Non-Preferred Brand Drugs																						Tier 3 Non-Preferred Brand Drugs	95.00	285.00								95.00			237.50								95.00			
H0532	001	0	1	01	01	H0532_001_0	4	2	3	1	Tier 2 Preferred Brand Drugs	000001		2	2	Tier 2 Preferred Brand Drugs	111000000010010000000	34	90								34			90								34	1	Tier 2 Preferred Brand Drugs	2	Tier 2 Preferred Brand Drugs																						Tier 2 Preferred Brand Drugs	43.00	129.00								43.00			107.50								43.00			
H0540	020	0	1	09	04	H0540_020_0	11	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H0540	020	0	1	09	04	H0540_020_0	11	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H0540	020	0	1	09	04	H0540_020_0	11	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H0540	020	0	1	09	04	H0540_020_0	11	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H0540	020	0	1	09	04	H0540_020_0	11	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H0540	020	0	1	09	04	H0540_020_0	11	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H0540	020	0	1	09	04	H0540_020_0	11	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H0540	020	0	1	09	04	H0540_020_0	11	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H0540	020	0	1	09	04	H0540_020_0	11	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H0540	020	0	1	09	04	H0540_020_0	11	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H0540	089	0	1	09	04	H0540_089_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H0540	089	0	1	09	04	H0540_089_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H0540	089	0	1	09	04	H0540_089_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H0540	089	0	1	09	04	H0540_089_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H0540	089	0	1	09	04	H0540_089_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H0540	089	0	1	09	04	H0540_089_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H0540	089	0	1	09	04	H0540_089_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H0540	089	0	1	09	04	H0540_089_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H0540	089	0	1	09	04	H0540_089_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H0540	089	0	1	09	04	H0540_089_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H0540	091	0	1	09	04	H0540_091_0	11	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H0540	091	0	1	09	04	H0540_091_0	11	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H0540	091	0	1	09	04	H0540_091_0	11	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H0540	091	0	1	09	04	H0540_091_0	11	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H0540	091	0	1	09	04	H0540_091_0	11	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H0540	091	0	1	09	04	H0540_091_0	11	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H0540	091	0	1	09	04	H0540_091_0	11	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H0540	091	0	1	09	04	H0540_091_0	11	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H0540	091	0	1	09	04	H0540_091_0	11	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H0540	091	0	1	09	04	H0540_091_0	11	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H0540	095	0	1	09	04	H0540_095_0	12	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H0540	095	0	1	09	04	H0540_095_0	12	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H0540	095	0	1	09	04	H0540_095_0	12	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H0540	095	0	1	09	04	H0540_095_0	12	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H0540	095	0	1	09	04	H0540_095_0	12	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H0540	095	0	1	09	04	H0540_095_0	12	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H0540	095	0	1	09	04	H0540_095_0	12	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H0540	095	0	1	09	04	H0540_095_0	12	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H0540	095	0	1	09	04	H0540_095_0	12	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H0540	095	0	1	09	04	H0540_095_0	12	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H0543	001	0	1	01	01	H0543_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00			
H0543	001	0	1	01	01	H0543_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H0543	001	0	1	01	01	H0543_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	001	0	1	01	01	H0543_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	004	0	1	01	01	H0543_004_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	004	0	1	01	01	H0543_004_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	004	0	1	01	01	H0543_004_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	004	0	1	01	01	H0543_004_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	007	0	1	01	01	H0543_007_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	007	0	1	01	01	H0543_007_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	007	0	1	01	01	H0543_007_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	007	0	1	01	01	H0543_007_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	013	0	1	01	01	H0543_013_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	013	0	1	01	01	H0543_013_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	013	0	1	01	01	H0543_013_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	013	0	1	01	01	H0543_013_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	013	0	1	01	01	H0543_013_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H0543	013	0	1	01	01	H0543_013_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	013	0	1	01	01	H0543_013_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	013	0	1	01	01	H0543_013_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0543	019	0	1	01	01	H0543_019_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	019	0	1	01	01	H0543_019_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	019	0	1	01	01	H0543_019_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	019	0	1	01	01	H0543_019_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	022	0	1	01	01	H0543_022_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	022	0	1	01	01	H0543_022_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	022	0	1	01	01	H0543_022_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	022	0	1	01	01	H0543_022_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	028	0	1	01	01	H0543_028_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	028	0	1	01	01	H0543_028_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	028	0	1	01	01	H0543_028_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	028	0	1	01	01	H0543_028_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	029	0	1	01	01	H0543_029_0	4	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H0543	029	0	1	01	01	H0543_029_0	4	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	8.00	24.00								8.00						16.00			24.00		8.00			
H0543	029	0	1	01	01	H0543_029_0	4	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	029	0	1	01	01	H0543_029_0	4	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	032	0	1	01	01	H0543_032_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	032	0	1	01	01	H0543_032_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	032	0	1	01	01	H0543_032_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	032	0	1	01	01	H0543_032_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	035	0	1	01	01	H0543_035_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	035	0	1	01	01	H0543_035_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	035	0	1	01	01	H0543_035_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	035	0	1	01	01	H0543_035_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	036	0	1	01	01	H0543_036_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	036	0	1	01	01	H0543_036_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	036	0	1	01	01	H0543_036_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	036	0	1	01	01	H0543_036_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	046	0	1	01	01	H0543_046_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	046	0	1	01	01	H0543_046_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	82.00	246.00								82.00						236.00			246.00		82.00			
H0543	046	0	1	01	01	H0543_046_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	046	0	1	01	01	H0543_046_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.50	19.50								6.50						13.00			19.50		6.50			
H0543	060	0	1	01	01	H0543_060_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	060	0	1	01	01	H0543_060_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	060	0	1	01	01	H0543_060_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	060	0	1	01	01	H0543_060_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	065	0	1	01	01	H0543_065_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	065	0	1	01	01	H0543_065_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	065	0	1	01	01	H0543_065_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00			
H0543	065	0	1	01	01	H0543_065_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H0543	070	0	1	01	01	H0543_070_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	070	0	1	01	01	H0543_070_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	070	0	1	01	01	H0543_070_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	070	0	1	01	01	H0543_070_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	077	0	1	01	01	H0543_077_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	077	0	1	01	01	H0543_077_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	077	0	1	01	01	H0543_077_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00			
H0543	077	0	1	01	01	H0543_077_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	077	0	1	01	01	H0543_077_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	077	0	1	01	01	H0543_077_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0543	077	0	1	01	01	H0543_077_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	077	0	1	01	01	H0543_077_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
H0543	082	0	1	01	01	H0543_082_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	082	0	1	01	01	H0543_082_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	082	0	1	01	01	H0543_082_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	082	0	1	01	01	H0543_082_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	083	0	1	01	01	H0543_083_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	083	0	1	01	01	H0543_083_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	083	0	1	01	01	H0543_083_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	083	0	1	01	01	H0543_083_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	083	0	1	01	01	H0543_083_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	083	0	1	01	01	H0543_083_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H0543	083	0	1	01	01	H0543_083_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0543	083	0	1	01	01	H0543_083_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	084	0	1	01	01	H0543_084_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	084	0	1	01	01	H0543_084_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	084	0	1	01	01	H0543_084_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	084	0	1	01	01	H0543_084_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	085	0	1	01	01	H0543_085_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	085	0	1	01	01	H0543_085_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	085	0	1	01	01	H0543_085_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	085	0	1	01	01	H0543_085_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	086	0	1	01	01	H0543_086_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	086	0	1	01	01	H0543_086_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	086	0	1	01	01	H0543_086_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	086	0	1	01	01	H0543_086_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	089	0	1	01	01	H0543_089_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	089	0	1	01	01	H0543_089_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	089	0	1	01	01	H0543_089_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	089	0	1	01	01	H0543_089_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	095	0	1	01	01	H0543_095_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H0543	095	0	1	01	01	H0543_095_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0543	095	0	1	01	01	H0543_095_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	095	0	1	01	01	H0543_095_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	095	0	1	01	01	H0543_095_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	095	0	1	01	01	H0543_095_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	095	0	1	01	01	H0543_095_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	095	0	1	01	01	H0543_095_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	44.00	132.00								44.00						122.00			132.00		44.00			
H0543	122	0	1	01	01	H0543_122_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	122	0	1	01	01	H0543_122_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	122	0	1	01	01	H0543_122_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H0543	122	0	1	01	01	H0543_122_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	122	0	1	01	01	H0543_122_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	122	0	1	01	01	H0543_122_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	122	0	1	01	01	H0543_122_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0543	122	0	1	01	01	H0543_122_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	125	0	1	01	01	H0543_125_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	125	0	1	01	01	H0543_125_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	125	0	1	01	01	H0543_125_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	125	0	1	01	01	H0543_125_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	127	0	1	01	01	H0543_127_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0543	127	0	1	01	01	H0543_127_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	127	0	1	01	01	H0543_127_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	127	0	1	01	01	H0543_127_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	127	0	1	01	01	H0543_127_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	127	0	1	01	01	H0543_127_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	127	0	1	01	01	H0543_127_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	127	0	1	01	01	H0543_127_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H0543	129	0	1	01	01	H0543_129_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	129	0	1	01	01	H0543_129_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00			
H0543	129	0	1	01	01	H0543_129_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	129	0	1	01	01	H0543_129_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	129	0	1	01	01	H0543_129_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	129	0	1	01	01	H0543_129_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	55.00	165.00								55.00						155.00			165.00		55.00	1	1	
H0543	129	0	1	01	01	H0543_129_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	12.00	36.00								12.00						24.00			36.00		12.00	1	1	
H0543	129	0	1	01	01	H0543_129_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	133	0	1	01	01	H0543_133_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	133	0	1	01	01	H0543_133_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	133	0	1	01	01	H0543_133_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	133	0	1	01	01	H0543_133_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	134	0	1	01	01	H0543_134_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	134	0	1	01	01	H0543_134_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	134	0	1	01	01	H0543_134_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	134	0	1	01	01	H0543_134_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	135	0	1	01	01	H0543_135_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	135	0	1	01	01	H0543_135_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	135	0	1	01	01	H0543_135_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	135	0	1	01	01	H0543_135_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	136	0	1	01	01	H0543_136_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	136	0	1	01	01	H0543_136_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	136	0	1	01	01	H0543_136_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	136	0	1	01	01	H0543_136_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	137	0	1	01	01	H0543_137_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	137	0	1	01	01	H0543_137_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	137	0	1	01	01	H0543_137_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0543	137	0	1	01	01	H0543_137_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0543	138	0	1	01	01	H0543_138_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00			
H0543	138	0	1	01	01	H0543_138_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0543	138	0	1	01	01	H0543_138_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00	1	1	
H0543	138	0	1	01	01	H0543_138_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
H0543	138	0	1	01	01	H0543_138_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	138	0	1	01	01	H0543_138_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	138	0	1	01	01	H0543_138_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	138	0	1	01	01	H0543_138_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0543	140	0	1	01	01	H0543_140_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	140	0	1	01	01	H0543_140_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	140	0	1	01	01	H0543_140_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0543	140	0	1	01	01	H0543_140_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0543	142	0	1	01	01	H0543_142_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0543	142	0	1	01	01	H0543_142_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H0543	142	0	1	01	01	H0543_142_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0543	142	0	1	01	01	H0543_142_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H0544	002	0	1	01	01	H0544_002_0	9	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	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	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	002	0	1	01	01	H0544_002_0	9	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	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	5	4	1	Brand Drugs	000010	3	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	002	0	1	01	01	H0544_002_0	9	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	003	0	1	01	01	H0544_003_0	9	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	9	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	003	0	1	01	01	H0544_003_0	9	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	1	Enhanced Care Brand Drugs	25	25								25			25								25	Enhanced Care Brand Drugs																								
H0544	003	0	1	01	01	H0544_003_0	9	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	1	Preferred Brand Drugs	25	25								25			25								25	Preferred Brand Drugs																								
H0544	003	0	1	01	01	H0544_003_0	9	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	1	Brand Drugs	25	25								25			25								25	Brand Drugs																								
H0544	003	0	1	01	01	H0544_003_0	9	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	003	0	1	01	01	H0544_003_0	9	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	003	0	1	01	01	H0544_003_0	9	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	003	0	1	01	01	H0544_003_0	9	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs																								Enhanced Care Brand Drugs		Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs																						2		
H0544	003	0	1	01	01	H0544_003_0	9	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	003	0	1	01	01	H0544_003_0	9	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	003	0	1	01	01	H0544_003_0	9	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																								
H0544	004	0	1	01	01	H0544_004_0	8	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00			
H0544	004	0	1	01	01	H0544_004_0	8	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	004	0	1	01	01	H0544_004_0	8	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00			
H0544	004	0	1	01	01	H0544_004_0	8	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	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	8	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	004	0	1	01	01	H0544_004_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	005	0	1	01	01	H0544_005_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																								
H0544	005	0	1	01	01	H0544_005_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00			
H0544	005	0	1	01	01	H0544_005_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	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	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	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	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	005	0	1	01	01	H0544_005_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	4	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	007	0	1	01	01	H0544_007_0	4	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	65.00	195.00								65.00			130.00								65.00			
H0544	007	0	1	01	01	H0544_007_0	4	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H0544	007	0	1	01	01	H0544_007_0	4	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	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	4	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	4	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00			16.00								8.00			
H0544	008	0	1	01	01	H0544_008_0	8	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	008	0	1	01	01	H0544_008_0	8	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	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	8	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	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	8	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	008	0	1	01	01	H0544_008_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	8	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	008	0	1	01	01	H0544_008_0	8	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	008	0	1	01	01	H0544_008_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	008	0	1	01	01	H0544_008_0	8	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs																								Enhanced Care Brand Drugs		Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs																						2		
H0544	008	0	1	01	01	H0544_008_0	8	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	008	0	1	01	01	H0544_008_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	008	0	1	01	01	H0544_008_0	8	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	009	0	1	01	01	H0544_009_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	8	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	009	0	1	01	01	H0544_009_0	8	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	1	Enhanced Care Brand Drugs	25	25								25			25								25	Enhanced Care Brand Drugs																								
H0544	009	0	1	01	01	H0544_009_0	8	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	1	Preferred Brand Drugs	25	25								25			25								25	Preferred Brand Drugs																								
H0544	009	0	1	01	01	H0544_009_0	8	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	1	Brand Drugs	25	25								25			25								25	Brand Drugs																								
H0544	009	0	1	01	01	H0544_009_0	8	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	009	0	1	01	01	H0544_009_0	8	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	009	0	1	01	01	H0544_009_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	009	0	1	01	01	H0544_009_0	8	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs																								Enhanced Care Brand Drugs		Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs																						2		
H0544	009	0	1	01	01	H0544_009_0	8	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																								
H0544	009	0	1	01	01	H0544_009_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	009	0	1	01	01	H0544_009_0	8	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	010	0	1	01	01	H0544_010_0	9	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	010	0	1	01	01	H0544_010_0	9	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	010	0	1	01	01	H0544_010_0	9	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	010	0	1	01	01	H0544_010_0	9	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	010	0	1	01	01	H0544_010_0	9	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	010	0	1	01	01	H0544_010_0	9	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	010	0	1	01	01	H0544_010_0	9	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	010	0	1	01	01	H0544_010_0	9	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	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	9	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	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	9	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	010	0	1	01	01	H0544_010_0	9	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	9	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	012	0	1	01	01	H0544_012_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	012	0	1	01	01	H0544_012_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	012	0	1	01	01	H0544_012_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	012	0	1	01	01	H0544_012_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00	1	1	
H0544	012	0	1	01	01	H0544_012_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	012	0	1	01	01	H0544_012_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	012	0	1	01	01	H0544_012_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	012	0	1	01	01	H0544_012_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	012	0	1	01	01	H0544_012_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	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	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	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	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	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	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	013	0	1	01	01	H0544_013_0	7	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00			
H0544	013	0	1	01	01	H0544_013_0	7	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	013	0	1	01	01	H0544_013_0	7	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	013	0	1	01	01	H0544_013_0	7	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	013	0	1	01	01	H0544_013_0	7	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	013	0	1	01	01	H0544_013_0	7	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00			
H0544	014	0	1	01	01	H0544_014_0	7	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	014	0	1	01	01	H0544_014_0	7	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	014	0	1	01	01	H0544_014_0	7	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	014	0	1	01	01	H0544_014_0	7	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00			
H0544	014	0	1	01	01	H0544_014_0	7	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00			
H0544	014	0	1	01	01	H0544_014_0	7	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	015	0	1	01	01	H0544_015_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	015	0	1	01	01	H0544_015_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	50.00	150.00								50.00			100.00								50.00			
H0544	015	0	1	01	01	H0544_015_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00								25.00			50.00								25.00			
H0544	015	0	1	01	01	H0544_015_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	015	0	1	01	01	H0544_015_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	015	0	1	01	01	H0544_015_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	016	0	1	01	01	H0544_016_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	75.00	225.00								75.00			150.00								75.00			
H0544	016	0	1	01	01	H0544_016_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0544	016	0	1	01	01	H0544_016_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00			
H0544	016	0	1	01	01	H0544_016_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00			20.00								10.00			
H0544	016	0	1	01	01	H0544_016_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	016	0	1	01	01	H0544_016_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	019	0	1	01	01	H0544_019_0	10	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	019	0	1	01	01	H0544_019_0	10	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	019	0	1	01	01	H0544_019_0	10	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	019	0	1	01	01	H0544_019_0	10	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	29.00	87.00								29.00			58.00								29.00			
H0544	019	0	1	01	01	H0544_019_0	10	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	019	0	1	01	01	H0544_019_0	10	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	019	0	1	01	01	H0544_019_0	10	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	019	0	1	01	01	H0544_019_0	10	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	019	0	1	01	01	H0544_019_0	10	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	019	0	1	01	01	H0544_019_0	10	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	019	0	1	01	01	H0544_019_0	10	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	019	0	1	01	01	H0544_019_0	10	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	020	0	1	01	01	H0544_020_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	020	0	1	01	01	H0544_020_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	020	0	1	01	01	H0544_020_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	020	0	1	01	01	H0544_020_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	29.00	87.00								29.00			58.00								29.00			
H0544	020	0	1	01	01	H0544_020_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	020	0	1	01	01	H0544_020_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	020	0	1	01	01	H0544_020_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	020	0	1	01	01	H0544_020_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	020	0	1	01	01	H0544_020_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	020	0	1	01	01	H0544_020_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	020	0	1	01	01	H0544_020_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	020	0	1	01	01	H0544_020_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	021	0	1	01	01	H0544_021_0	5	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	021	0	1	01	01	H0544_021_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	021	0	1	01	01	H0544_021_0	5	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0544	021	0	1	01	01	H0544_021_0	5	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	021	0	1	01	01	H0544_021_0	5	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	75.00	225.00								75.00			150.00								75.00			
H0544	021	0	1	01	01	H0544_021_0	5	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	55.00	165.00								55.00			110.00								55.00			
H0544	022	0	1	01	01	H0544_022_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	022	0	1	01	01	H0544_022_0	5	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	022	0	1	01	01	H0544_022_0	5	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	022	0	1	01	01	H0544_022_0	5	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00			
H0544	022	0	1	01	01	H0544_022_0	5	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	022	0	1	01	01	H0544_022_0	5	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	022	0	1	01	01	H0544_022_0	5	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	022	0	1	01	01	H0544_022_0	5	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	022	0	1	01	01	H0544_022_0	5	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	022	0	1	01	01	H0544_022_0	5	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	022	0	1	01	01	H0544_022_0	5	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	022	0	1	01	01	H0544_022_0	5	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	024	0	1	01	01	H0544_024_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	024	0	1	01	01	H0544_024_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	024	0	1	01	01	H0544_024_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	024	0	1	01	01	H0544_024_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	024	0	1	01	01	H0544_024_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	024	0	1	01	01	H0544_024_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	024	0	1	01	01	H0544_024_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	024	0	1	01	01	H0544_024_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	024	0	1	01	01	H0544_024_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	024	0	1	01	01	H0544_024_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	024	0	1	01	01	H0544_024_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	024	0	1	01	01	H0544_024_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00			
H0544	025	0	1	01	01	H0544_025_0	7	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	025	0	1	01	01	H0544_025_0	7	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	025	0	1	01	01	H0544_025_0	7	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	025	0	1	01	01	H0544_025_0	7	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	025	0	1	01	01	H0544_025_0	7	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	025	0	1	01	01	H0544_025_0	7	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	025	0	1	01	01	H0544_025_0	7	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00			
H0544	025	0	1	01	01	H0544_025_0	7	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	025	0	1	01	01	H0544_025_0	7	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	025	0	1	01	01	H0544_025_0	7	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	025	0	1	01	01	H0544_025_0	7	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	025	0	1	01	01	H0544_025_0	7	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	027	0	1	01	01	H0544_027_0	8	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	027	0	1	01	01	H0544_027_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	027	0	1	01	01	H0544_027_0	8	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00			
H0544	027	0	1	01	01	H0544_027_0	8	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	027	0	1	01	01	H0544_027_0	8	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	027	0	1	01	01	H0544_027_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	027	0	1	01	01	H0544_027_0	8	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00	1	1	
H0544	027	0	1	01	01	H0544_027_0	8	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	027	0	1	01	01	H0544_027_0	8	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00			
H0544	027	0	1	01	01	H0544_027_0	8	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	027	0	1	01	01	H0544_027_0	8	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	027	0	1	01	01	H0544_027_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	028	0	1	01	01	H0544_028_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	028	0	1	01	01	H0544_028_0	5	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	75.00	225.00								75.00			150.00								75.00			
H0544	028	0	1	01	01	H0544_028_0	5	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	55.00	165.00								55.00			110.00								55.00			
H0544	028	0	1	01	01	H0544_028_0	5	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0544	028	0	1	01	01	H0544_028_0	5	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	028	0	1	01	01	H0544_028_0	5	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	031	0	1	01	01	H0544_031_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	031	0	1	01	01	H0544_031_0	5	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	031	0	1	01	01	H0544_031_0	5	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	031	0	1	01	01	H0544_031_0	5	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	031	0	1	01	01	H0544_031_0	5	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	031	0	1	01	01	H0544_031_0	5	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	031	0	1	01	01	H0544_031_0	5	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	031	0	1	01	01	H0544_031_0	5	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	031	0	1	01	01	H0544_031_0	5	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	031	0	1	01	01	H0544_031_0	5	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	031	0	1	01	01	H0544_031_0	5	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00			
H0544	031	0	1	01	01	H0544_031_0	5	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	032	0	1	01	01	H0544_032_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	032	0	1	01	01	H0544_032_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0544	032	0	1	01	01	H0544_032_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H0544	032	0	1	01	01	H0544_032_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0544	032	0	1	01	01	H0544_032_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H0544	032	0	1	01	01	H0544_032_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0544	032	0	1	01	01	H0544_032_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0544	032	0	1	01	01	H0544_032_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0544	032	0	1	01	01	H0544_032_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00								30.00			60.00								30.00			
H0544	032	0	1	01	01	H0544_032_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H0544	032	0	1	01	01	H0544_032_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H0544	032	0	1	01	01	H0544_032_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H0545	001	0	1	01	01	H0545_001_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00			4.00								2.00			
H0545	001	0	1	01	01	H0545_001_0	6	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	31	90								31			90								31	2	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H0545	001	0	1	01	01	H0545_001_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00			58.00								29.00			
H0545	001	0	1	01	01	H0545_001_0	6	4	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00			
H0545	001	0	1	01	01	H0545_001_0	6	5	4	1	Injectables	010010	1	2	2	Injectables	111000000010010000000	31	90								31			90								31	2	Injectables	1	Injectables	10	10								10			10								10	Injectables																								
H0545	001	0	1	01	01	H0545_001_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0545	001	0	1	01	01	H0545_001_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.00	6.00								2.00			4.00								2.00	1	1	
H0545	001	0	1	01	01	H0545_001_0	6	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic																								Non-Preferred Generic		Non-Preferred Generic																						Non-Preferred Generic																						2		
H0545	001	0	1	01	01	H0545_001_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0545	001	0	1	01	01	H0545_001_0	6	4	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0545	001	0	1	01	01	H0545_001_0	6	5	4	3	Injectables	010010	1	2	2	Injectables																								Injectables		Injectables																						Injectables																						2		
H0545	001	0	1	01	01	H0545_001_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	31									31											31		Specialty Drugs	1	Specialty Drugs	25									25											25	Specialty Drugs																								
H0545	009	0	1	01	01	H0545_009_0	6	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic																								Non-Preferred Generic		Non-Preferred Generic																						Non-Preferred Generic																						2		
H0545	009	0	1	01	01	H0545_009_0	6	3	4	3	Other Special Needs	000010	1	2	2	Other Special Needs	111000000010010000000	31	90								31			90								31	2	Other Special Needs	2	Other Special Needs																						Other Special Needs	18.00	54.00								18.00			36.00								18.00	1	1	
H0545	009	0	1	01	01	H0545_009_0	6	4	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0545	009	0	1	01	01	H0545_009_0	6	5	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0545	009	0	1	01	01	H0545_009_0	6	6	4	3	Injectables	010010	1	2	2	Injectables																								Injectables		Injectables																						Injectables																						2		
H0545	009	0	1	01	01	H0545_009_0	6	7	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0545	009	0	1	01	01	H0545_009_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			8.00								4.00			
H0545	009	0	1	01	01	H0545_009_0	6	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	31	90								31			90								31	2	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	8.00	24.00								8.00			16.00								8.00			
H0545	009	0	1	01	01	H0545_009_0	6	3	4	1	Other Special Needs	000010	1	2	2	Other Special Needs	111000000010010000000	31	90								31			90								31	2	Other Special Needs	2	Other Special Needs																						Other Special Needs	18.00	54.00								18.00			36.00								18.00			
H0545	009	0	1	01	01	H0545_009_0	6	4	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	29.00	87.00								29.00			58.00								29.00			
H0545	009	0	1	01	01	H0545_009_0	6	5	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00			110.00								55.00			
H0545	009	0	1	01	01	H0545_009_0	6	6	4	1	Injectables	010010	1	2	2	Injectables	111000000010010000000	31	90								31			90								31	2	Injectables	1	Injectables	10	10								10			10								10	Injectables																								
H0545	009	0	1	01	01	H0545_009_0	6	7	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	31									31											31		Specialty Drugs	1	Specialty Drugs	25									25											25	Specialty Drugs																								
H0545	009	0	1	01	01	H0545_009_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			8.00								4.00	1	1	
H0545	011	0	1	01	01	H0545_011_0	4	5	4	1	Injectables	010010	1	2	2	Injectables	111000000010010000000	31	90								31			90								31	2	Injectables	1	Injectables	10	10								10			10								10	Injectables																								
H0545	011	0	1	01	01	H0545_011_0	4	4	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	49.00	147.00								49.00			147.00								49.00			
H0545	011	0	1	01	01	H0545_011_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.50	118.50								39.50			118.50								39.50			
H0545	011	0	1	01	01	H0545_011_0	4	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	31	90								31			90								31	2	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	14.00	42.00								14.00			42.00								14.00			
H0545	011	0	1	01	01	H0545_011_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			30.00								10.00			
H0545	011	0	1	01	01	H0545_011_0	4	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	31									31											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H0545	012	0	1	01	01	H0545_012_0	5	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H0545	012	0	1	01	01	H0545_012_0	5	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	31	90								31			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	3.00	9.00								3.00			9.00								3.00	1	1	
H0545	012	0	1	01	01	H0545_012_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0545	012	0	1	01	01	H0545_012_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0545	012	0	1	01	01	H0545_012_0	5	5	4	3	Injectables	000010	1	2	2	Injectables																								Injectables		Injectables																						Injectables																						2		
H0545	012	0	1	01	01	H0545_012_0	5	6	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010010000000	31	90								31			90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																								
H0545	012	0	1	01	01	H0545_012_0	5	5	4	1	Injectables	000010	1	2	2	Injectables	111000000010010000000	31	90								31			90								31	1	Injectables	1	Injectables	10	10								10			10								10	Injectables																								
H0545	012	0	1	01	01	H0545_012_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H0545	012	0	1	01	01	H0545_012_0	5	6	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010010000000	31	90								31			90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																						1	1	
H0545	012	0	1	01	01	H0545_012_0	5	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	31	90								31			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	3.00	9.00								3.00			9.00								3.00			
H0545	012	0	1	01	01	H0545_012_0	5	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H0545	012	0	1	01	01	H0545_012_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H0562	002	0	1	01	01	H0562_002_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	002	0	1	01	01	H0562_002_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	002	0	1	01	01	H0562_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																						2		
H0562	002	0	1	01	01	H0562_002_0	4	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	002	0	1	01	01	H0562_002_0	4	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	002	0	1	01	01	H0562_002_0	4	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	002	0	1	01	01	H0562_002_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	002	0	1	01	01	H0562_002_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	002	0	1	01	01	H0562_002_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	002	0	1	01	01	H0562_002_0	4	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	009	0	1	01	01	H0562_009_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	009	0	1	01	01	H0562_009_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	009	0	1	01	01	H0562_009_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	009	0	1	01	01	H0562_009_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	009	0	1	01	01	H0562_009_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	010	0	1	01	01	H0562_010_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	010	0	1	01	01	H0562_010_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	010	0	1	01	01	H0562_010_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	010	0	1	01	01	H0562_010_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	010	0	1	01	01	H0562_010_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	011	0	1	01	01	H0562_011_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	011	0	1	01	01	H0562_011_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	011	0	1	01	01	H0562_011_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	011	0	1	01	01	H0562_011_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	011	0	1	01	01	H0562_011_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	012	0	1	01	01	H0562_012_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	012	0	1	01	01	H0562_012_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	012	0	1	01	01	H0562_012_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	012	0	1	01	01	H0562_012_0	3	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	012	0	1	01	01	H0562_012_0	3	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	012	0	1	01	01	H0562_012_0	3	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	012	0	1	01	01	H0562_012_0	3	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	012	0	1	01	01	H0562_012_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	012	0	1	01	01	H0562_012_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	012	0	1	01	01	H0562_012_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	017	0	1	01	01	H0562_017_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	017	0	1	01	01	H0562_017_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	017	0	1	01	01	H0562_017_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	017	0	1	01	01	H0562_017_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	017	0	1	01	01	H0562_017_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	036	0	1	01	01	H0562_036_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	036	0	1	01	01	H0562_036_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	036	0	1	01	01	H0562_036_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	036	0	1	01	01	H0562_036_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	036	0	1	01	01	H0562_036_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	037	0	1	01	01	H0562_037_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	037	0	1	01	01	H0562_037_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	037	0	1	01	01	H0562_037_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	037	0	1	01	01	H0562_037_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	037	0	1	01	01	H0562_037_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	039	0	1	01	01	H0562_039_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	039	0	1	01	01	H0562_039_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	039	0	1	01	01	H0562_039_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	039	0	1	01	01	H0562_039_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	039	0	1	01	01	H0562_039_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	040	0	1	01	01	H0562_040_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	040	0	1	01	01	H0562_040_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	040	0	1	01	01	H0562_040_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	040	0	1	01	01	H0562_040_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	040	0	1	01	01	H0562_040_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	053	0	1	01	01	H0562_053_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	053	0	1	01	01	H0562_053_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	053	0	1	01	01	H0562_053_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	053	0	1	01	01	H0562_053_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	053	0	1	01	01	H0562_053_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	058	0	1	01	01	H0562_058_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	058	0	1	01	01	H0562_058_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	058	0	1	01	01	H0562_058_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	058	0	1	01	01	H0562_058_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	058	0	1	01	01	H0562_058_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	059	0	1	01	01	H0562_059_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	059	0	1	01	01	H0562_059_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	059	0	1	01	01	H0562_059_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	059	0	1	01	01	H0562_059_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	059	0	1	01	01	H0562_059_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	060	0	1	01	01	H0562_060_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	060	0	1	01	01	H0562_060_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	060	0	1	01	01	H0562_060_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	060	0	1	01	01	H0562_060_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	060	0	1	01	01	H0562_060_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	061	0	1	01	01	H0562_061_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	061	0	1	01	01	H0562_061_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	061	0	1	01	01	H0562_061_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	061	0	1	01	01	H0562_061_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	061	0	1	01	01	H0562_061_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	062	0	1	01	01	H0562_062_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	062	0	1	01	01	H0562_062_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	062	0	1	01	01	H0562_062_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	062	0	1	01	01	H0562_062_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	062	0	1	01	01	H0562_062_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	068	0	1	01	01	H0562_068_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	068	0	1	01	01	H0562_068_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	068	0	1	01	01	H0562_068_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	068	0	1	01	01	H0562_068_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	068	0	1	01	01	H0562_068_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	071	0	1	01	01	H0562_071_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	071	0	1	01	01	H0562_071_0	3	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	071	0	1	01	01	H0562_071_0	3	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	071	0	1	01	01	H0562_071_0	3	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	071	0	1	01	01	H0562_071_0	3	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	071	0	1	01	01	H0562_071_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	071	0	1	01	01	H0562_071_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	071	0	1	01	01	H0562_071_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	071	0	1	01	01	H0562_071_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	071	0	1	01	01	H0562_071_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	076	0	1	01	01	H0562_076_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	076	0	1	01	01	H0562_076_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	076	0	1	01	01	H0562_076_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	076	0	1	01	01	H0562_076_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	076	0	1	01	01	H0562_076_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	077	0	1	01	01	H0562_077_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	077	0	1	01	01	H0562_077_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	077	0	1	01	01	H0562_077_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	077	0	1	01	01	H0562_077_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	077	0	1	01	01	H0562_077_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	079	0	1	01	01	H0562_079_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	079	0	1	01	01	H0562_079_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					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	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	079	0	1	01	01	H0562_079_0	5	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	079	0	1	01	01	H0562_079_0	5	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	079	0	1	01	01	H0562_079_0	5	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	079	0	1	01	01	H0562_079_0	5	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	079	0	1	01	01	H0562_079_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	079	0	1	01	01	H0562_079_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	079	0	1	01	01	H0562_079_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	081	0	1	01	01	H0562_081_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	081	0	1	01	01	H0562_081_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	081	0	1	01	01	H0562_081_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	081	0	1	01	01	H0562_081_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	081	0	1	01	01	H0562_081_0	3	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	081	0	1	01	01	H0562_081_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	081	0	1	01	01	H0562_081_0	3	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	081	0	1	01	01	H0562_081_0	3	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	081	0	1	01	01	H0562_081_0	3	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	081	0	1	01	01	H0562_081_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	082	0	1	01	01	H0562_082_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	082	0	1	01	01	H0562_082_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	082	0	1	01	01	H0562_082_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	082	0	1	01	01	H0562_082_0	3	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	082	0	1	01	01	H0562_082_0	3	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	082	0	1	01	01	H0562_082_0	3	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	082	0	1	01	01	H0562_082_0	3	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	082	0	1	01	01	H0562_082_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	082	0	1	01	01	H0562_082_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	082	0	1	01	01	H0562_082_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	083	0	1	01	01	H0562_083_0	3	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	083	0	1	01	01	H0562_083_0	3	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	083	0	1	01	01	H0562_083_0	3	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	083	0	1	01	01	H0562_083_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	083	0	1	01	01	H0562_083_0	3	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	083	0	1	01	01	H0562_083_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	083	0	1	01	01	H0562_083_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	083	0	1	01	01	H0562_083_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0562	083	0	1	01	01	H0562_083_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	083	0	1	01	01	H0562_083_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	084	0	1	01	01	H0562_084_0	4	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	084	0	1	01	01	H0562_084_0	4	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	7.00	21.00	14.00							7.00					7.00	14.00	14.00	7.00	21.00	14.00	7.00			
H0562	084	0	1	01	01	H0562_084_0	4	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	084	0	1	01	01	H0562_084_0	4	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	084	0	1	01	01	H0562_084_0	4	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	085	0	1	01	01	H0562_085_0	3	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0562	085	0	1	01	01	H0562_085_0	3	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0562	085	0	1	01	01	H0562_085_0	3	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H0562	085	0	1	01	01	H0562_085_0	3	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H0562	085	0	1	01	01	H0562_085_0	3	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00	1	1	
H0562	085	0	1	01	01	H0562_085_0	3	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0562	085	0	1	01	01	H0562_085_0	3	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0562	085	0	1	01	01	H0562_085_0	3	5	4	3	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty																								Tier 5 Specialty		Tier 5 Specialty																						Tier 5 Specialty																						2		
H0562	085	0	1	01	01	H0562_085_0	3	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0562	085	0	1	01	01	H0562_085_0	3	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H0564	006	0	1	01	01	H0564_006_0	8	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H0564	006	0	1	01	01	H0564_006_0	8	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H0564	006	0	1	01	01	H0564_006_0	8	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H0564	006	0	1	01	01	H0564_006_0	8	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H0564	006	0	1	01	01	H0564_006_0	8	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H0564	006	0	1	01	01	H0564_006_0	8	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H0564	006	0	1	01	01	H0564_006_0	8	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H0564	006	0	1	01	01	H0564_006_0	8	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H0564	006	0	1	01	01	H0564_006_0	8	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H0564	006	0	1	01	01	H0564_006_0	8	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H0564	047	0	1	01	01	H0564_047_0	8	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H0564	047	0	1	01	01	H0564_047_0	8	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H0564	047	0	1	01	01	H0564_047_0	8	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H0564	047	0	1	01	01	H0564_047_0	8	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H0564	047	0	1	01	01	H0564_047_0	8	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H0564	047	0	1	01	01	H0564_047_0	8	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H0564	047	0	1	01	01	H0564_047_0	8	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H0564	047	0	1	01	01	H0564_047_0	8	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H0564	047	0	1	01	01	H0564_047_0	8	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H0564	047	0	1	01	01	H0564_047_0	8	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H0571	001	0	1	01	01	H0571_001_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00			
H0571	001	0	1	01	01	H0571_001_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	35.00	70.00								35.00			70.00								35.00			
H0571	002	0	2	01	01	H0571_002_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00			
H0571	002	0	2	01	01	H0571_002_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	35.00	70.00								35.00			70.00								35.00			
H0571	006	0	1	01	01	H0571_006_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	20.00								10.00			20.00								10.00			
H0571	006	0	1	01	01	H0571_006_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	35.00	70.00								35.00			70.00								35.00			
H0602	017	0	1	18	06	H0602_017_0	13	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	017	0	1	18	06	H0602_017_0	13	3	4	1	NonPreferred Brand Drugs	100000	1	2	2	NonPreferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	NonPreferred Brand Drugs	2	NonPreferred Brand Drugs																						NonPreferred Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0602	017	0	1	18	06	H0602_017_0	13	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	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	13	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00			20.00								10.00			
H0602	018	0	1	18	06	H0602_018_0	17	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	018	0	1	18	06	H0602_018_0	17	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	58.00	174.00								58.00			116.00								58.00			
H0602	018	0	1	18	06	H0602_018_0	17	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.50	25.50								8.50			17.00								8.50	1	1	
H0602	018	0	1	18	06	H0602_018_0	17	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0602	018	0	1	18	06	H0602_018_0	17	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.50	25.50								8.50			17.00								8.50			
H0602	018	0	1	18	06	H0602_018_0	17	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0602	018	0	1	18	06	H0602_018_0	17	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0602	018	0	1	18	06	H0602_018_0	17	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			76.00								38.00			
H0602	019	0	1	18	06	H0602_019_0	14	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00			112.00								56.00			
H0602	019	0	1	18	06	H0602_019_0	14	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	019	0	1	18	06	H0602_019_0	14	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.50	25.50								8.50			17.00								8.50	1	1	
H0602	019	0	1	18	06	H0602_019_0	14	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0602	019	0	1	18	06	H0602_019_0	14	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H0602	019	0	1	18	06	H0602_019_0	14	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0602	019	0	1	18	06	H0602_019_0	14	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			72.00								36.00			
H0602	019	0	1	18	06	H0602_019_0	14	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.50	25.50								8.50			17.00								8.50			
H0602	020	0	1	18	06	H0602_020_0	12	3	4	1	Non-Preferred Drugs	100000	1	2	2	Non-Preferred Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Drugs	2	Non-Preferred Drugs																						Non-Preferred Drugs	60.00	180.00								60.00			120.00								60.00			
H0602	020	0	1	18	06	H0602_020_0	12	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	020	0	1	18	06	H0602_020_0	12	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0602	020	0	1	18	06	H0602_020_0	12	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00			20.00								10.00			
H0602	021	0	1	18	06	H0602_021_0	14	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0602	021	0	1	18	06	H0602_021_0	14	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			17.00								8.50	1	1	
H0602	021	0	1	18	06	H0602_021_0	14	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	021	0	1	18	06	H0602_021_0	14	3	4	1	Non-Preferred Drugs	000001	1	2	2	Non-Preferred Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Drugs	2	Non-Preferred Drugs																						Non-Preferred Drugs	58.00	174.00								58.00			116.00								58.00			
H0602	021	0	1	18	06	H0602_021_0	14	3	4	3	Non-Preferred Drugs	000001	1	2	2	Non-Preferred Drugs																								Non-Preferred Drugs		Non-Preferred Drugs																						Non-Preferred Drugs																						2		
H0602	021	0	1	18	06	H0602_021_0	14	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H0602	021	0	1	18	06	H0602_021_0	14	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			76.00								38.00			
H0602	021	0	1	18	06	H0602_021_0	14	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			17.00								8.50			
H0602	022	0	1	18	06	H0602_022_0	12	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	022	0	1	18	06	H0602_022_0	12	3	4	1	Non-Preferred Brand Drugs	100000	1	2	2	Non-Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand Drugs	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	12	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00			20.00								10.00			
H0602	022	0	1	18	06	H0602_022_0	12	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	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	12	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00			
H0602	023	0	1	18	06	H0602_023_0	12	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	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	12	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00			20.00								10.00			
H0602	023	0	1	18	06	H0602_023_0	12	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H0602	036	0	1	18	06	H0602_036_0	15	3	3	1	Non-Preferred Brand Drugs	100000		2	2	Non-Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0602	036	0	1	18	06	H0602_036_0	15	2	3	1	Preferred Brand Drugs	000001		2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0602	036	0	1	18	06	H0602_036_0	15	1	3	1	Generic Drugs	010000		2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	12.00	36.00								12.00			24.00								12.00			
H0602	036	0	1	18	06	H0602_036_0	15	4	3	1	Specialty Drugs	010010		1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	30	30								30			30								30	Specialty Drugs																								
H0602	038	0	1	18	06	H0602_038_0	14	4	3	1	Specialty Drugs	010010		1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	30	30								30			30								30	Specialty Drugs																								
H0602	038	0	1	18	06	H0602_038_0	14	3	3	1	Non-Preferred Brand Drugs	100000		2	2	Non-Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0602	038	0	1	18	06	H0602_038_0	14	1	3	1	Generic Drugs	010000		2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	12.00	36.00								12.00			24.00								12.00			
H0602	038	0	1	18	06	H0602_038_0	14	2	3	1	Preferred Brand Drugs	000001		2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0602	039	0	1	18	06	H0602_039_0	15	3	3	1	Non-Preferred Brand Drugs	100000		2	2	Non-Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H0602	039	0	1	18	06	H0602_039_0	15	4	3	1	Specialty Drugs	010010		1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	30	30								30			30								30	Specialty Drugs																								
H0602	039	0	1	18	06	H0602_039_0	15	2	3	1	Preferred Brand Drugs	000001		2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	40.00	120.00								40.00			80.00								40.00			
H0602	039	0	1	18	06	H0602_039_0	15	1	3	1	Generic Drugs	010000		2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	12.00	36.00								12.00			24.00								12.00			
H0602	043	0	1	18	06	H0602_043_0	14	1	3	1	Generic Drugs	010000		2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	12.00	36.00								12.00			24.00								12.00			
H0602	043	0	1	18	06	H0602_043_0	14	3	3	1	Non-Preferred Drugs	100000		2	2	Non-Preferred Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Drugs	2	Non-Preferred Drugs																						Non-Preferred Drugs	56.00	168.00								56.00			112.00								56.00			
H0602	043	0	1	18	06	H0602_043_0	14	4	3	1	Specialty Drugs	000010		1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	30	30								30			30								30	Specialty Drugs																								
H0602	043	0	1	18	06	H0602_043_0	14	2	3	1	Preferred Brand Drugs	000001		2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	36.00	108.00								36.00			72.00								36.00			
H0602	045	0	1	18	06	H0602_045_0	14	1	3	1	Generic Drugs	010000		2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	11.50	34.50								11.50			23.00								11.50			
H0602	045	0	1	18	06	H0602_045_0	14	2	3	1	Preferred Brand Drugs	000001		2	1	Preferred Brand Drugs	111000000010010000000	30	90								30			90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H0602	045	0	1	18	06	H0602_045_0	14	3	3	1	Non-Preferred Drugs	100000		2	2	Non-Preferred Drugs	111000000010010000000	30	90								30			90								31	1	Non-Preferred Drugs	2	Non-Preferred Drugs																						Non-Preferred Drugs	55.00	165.00								55.00			110.00								55.00			
H0602	045	0	1	18	06	H0602_045_0	14	4	3	1	Specialty Drugs	000010		1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	30	30								30			30								30	Specialty Drugs																								
H0609	002	0	1	01	01	H0609_002_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H0609	002	0	1	01	01	H0609_002_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0609	002	0	1	01	01	H0609_002_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H0609	002	0	1	01	01	H0609_002_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H0609	002	0	1	01	01	H0609_002_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H0609	002	0	1	01	01	H0609_002_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H0609	002	0	1	01	01	H0609_002_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0609	002	0	1	01	01	H0609_002_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H0609	006	0	1	01	01	H0609_006_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H0609	006	0	1	01	01	H0609_006_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H0609	006	0	1	01	01	H0609_006_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0609	006	0	1	01	01	H0609_006_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0609	007	0	1	01	01	H0609_007_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0609	007	0	1	01	01	H0609_007_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0609	007	0	1	01	01	H0609_007_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H0609	007	0	1	01	01	H0609_007_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H0609	012	0	1	01	01	H0609_012_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H0609	012	0	1	01	01	H0609_012_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H0609	012	0	1	01	01	H0609_012_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0609	012	0	1	01	01	H0609_012_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0609	020	0	1	01	01	H0609_020_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H0609	020	0	1	01	01	H0609_020_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0609	020	0	1	01	01	H0609_020_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0609	020	0	1	01	01	H0609_020_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H0621	004	0	1	01	01	H0621_004_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	3	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 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	3	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	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	3	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H0621	004	0	1	01	01	H0621_004_0	3	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	6.00								3.00	1	1	
H0621	004	0	1	01	01	H0621_004_0	3	2	4	3	Tier 2	010001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	1	Tier 2	50	50								50		40	40								50	Tier 2																						1	1	
H0621	004	0	1	01	01	H0621_004_0	3	3	4	3	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	1	Tier 3	60	60								60		50	50								60	Tier 3																						1	1	
H0621	004	0	1	01	01	H0621_004_0	3	4	4	3	Tier 4	000010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	1	Tier 4	60	60								60		50	50								60	Tier 4																						1	1	
H0621	005	0	1	01	01	H0621_005_0	3	2	4	3	Tier 2	010001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	1	Tier 2	50	50								50		40	40								50	Tier 2																						1	1	
H0621	005	0	1	01	01	H0621_005_0	3	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	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	3	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 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	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	3	4	4	3	Tier 4	000010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	1	Tier 4	60	60								60		50	50								60	Tier 4																						1	1	
H0621	005	0	1	01	01	H0621_005_0	3	3	4	3	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	1	Tier 3	60	60								60		50	50								60	Tier 3																						1	1	
H0621	005	0	1	01	01	H0621_005_0	3	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H0621	005	0	1	01	01	H0621_005_0	3	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	6.00								3.00	1	1	
H0621	006	0	1	01	01	H0621_006_0	3	2	2	1	Tier 2	010001		2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	2	Tier 2	1	Tier 2	37	37								37		27	27								37	Tier 2																								
H0621	006	0	1	01	01	H0621_006_0	3	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	1	Tier 3	60	60								60		50	50								60	Tier 3																								
H0621	006	0	1	01	01	H0621_006_0	3	4	2	1	Tier 4	000010		1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	1	Tier 4	25	25								25		25	25								25	Tier 4																								
H0621	006	0	1	01	01	H0621_006_0	3	1	2	1	Tier 1	001000		2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H0621	007	0	1	01	01	H0621_007_0	6	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H0621	007	0	1	01	01	H0621_007_0	6	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H0621	007	0	1	01	01	H0621_007_0	6	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	1.00	3.00								1.00		1.00	2.00								1.00	1	1	
H0621	007	0	1	01	01	H0621_007_0	6	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	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	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	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	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00		38.00	76.00								38.00			
H0621	007	0	1	01	01	H0621_007_0	6	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	1.00	3.00								1.00		1.00	2.00								1.00			
H0621	007	0	1	01	01	H0621_007_0	6	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H0621	009	0	1	01	01	H0621_009_0	4	1	2	1	Tier 1	001000		2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H0621	009	0	1	01	01	H0621_009_0	4	2	2	1	Tier 2	010001		2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	1	Tier 2	32	32								32		22	22								32	Tier 2																								
H0621	009	0	1	01	01	H0621_009_0	4	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	1	Tier 3	50	50								50		40	40								50	Tier 3																								
H0621	009	0	1	01	01	H0621_009_0	4	4	2	1	Tier 4	000010		1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	2	Tier 4	1	Tier 4	25	25								25		25	25								25	Tier 4																								
H0623	001	0	1	04	01	H0623_001_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0623	001	0	1	04	01	H0623_001_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H0623	001	0	1	04	01	H0623_001_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0623	001	0	1	04	01	H0623_001_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0623	001	0	1	04	01	H0623_001_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0623	001	0	1	04	01	H0623_001_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H0623	005	0	1	04	01	H0623_005_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H0623	005	0	1	04	01	H0623_005_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H0623	005	0	1	04	01	H0623_005_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H0623	005	0	1	04	01	H0623_005_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H0623	005	0	1	04	01	H0623_005_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H0623	005	0	1	04	01	H0623_005_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H0623	005	0	1	04	01	H0623_005_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H0624	005	0	1	01	01	H0624_005_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0624	005	0	1	01	01	H0624_005_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0624	005	0	1	01	01	H0624_005_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0624	005	0	1	01	01	H0624_005_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0630	013	0	1	01	01	H0630_013_0	4	3	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0630	013	0	1	01	01	H0630_013_0	4	2	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0630	013	0	1	01	01	H0630_013_0	4	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00		10.00	20.00								10.00			
H0630	013	0	1	01	01	H0630_013_0	4	2	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010110000000	30	90								30		30	90								31	2	Brand Drugs	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	4	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H0630	013	0	1	01	01	H0630_013_0	4	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H0630	015	0	1	01	01	H0630_015_0	5	3	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0630	015	0	1	01	01	H0630_015_0	5	2	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0630	015	0	1	01	01	H0630_015_0	5	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H0630	015	0	1	01	01	H0630_015_0	5	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H0630	015	0	1	01	01	H0630_015_0	5	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00		10.00	20.00								10.00			
H0630	015	0	1	01	01	H0630_015_0	5	2	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010110000000	30	90								30		30	90								31	2	Brand Drugs	2	Brand Drugs																						Brand Drugs	35.00	105.00								35.00		35.00	70.00								35.00			
H0630	016	0	1	01	01	H0630_016_0	4	2	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0630	016	0	1	01	01	H0630_016_0	4	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H0630	016	0	1	01	01	H0630_016_0	4	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H0630	016	0	1	01	01	H0630_016_0	4	2	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010110000000	30	90								30		30	90								31	2	Brand Drugs	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	4	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00			
H0630	016	0	1	01	01	H0630_016_0	4	3	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0630	017	0	1	01	01	H0630_017_0	3	3	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0630	017	0	1	01	01	H0630_017_0	3	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	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	3	2	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010110000000	30	90								30		30	90								31	2	Brand Drugs	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	3	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H0630	017	0	1	01	01	H0630_017_0	3	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	9.00	27.00								9.00		9.00	18.00								9.00	1	1	
H0630	017	0	1	01	01	H0630_017_0	3	2	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0630	018	0	1	01	01	H0630_018_0	4	3	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0630	018	0	1	01	01	H0630_018_0	4	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H0630	018	0	1	01	01	H0630_018_0	4	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H0630	018	0	1	01	01	H0630_018_0	4	2	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010110000000	30	90								30		30	90								31	2	Brand Drugs	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	4	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	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	4	2	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0630	019	0	1	02	01	H0630_019_0	4	3	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H0630	019	0	1	02	01	H0630_019_0	4	2	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H0630	019	0	1	02	01	H0630_019_0	4	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H0630	019	0	1	02	01	H0630_019_0	4	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H0630	019	0	1	02	01	H0630_019_0	4	2	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010110000000	30	90								30		30	90								31	2	Brand Drugs	2	Brand Drugs																						Brand Drugs	35.00	105.00								35.00		35.00	70.00								35.00			
H0630	019	0	1	02	01	H0630_019_0	4	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010110000000	30	90								30		30	90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	10.00	30.00								10.00		10.00	20.00								10.00			
H0710	003	0	1	04	01	H0710_003_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0710	003	0	1	04	01	H0710_003_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H0710	003	0	1	04	01	H0710_003_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H0710	003	0	1	04	01	H0710_003_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H0712	001	0	1	02	01	H0712_001_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0712	001	0	1	02	01	H0712_001_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H0712	001	0	1	02	01	H0712_001_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H0712	005	0	1	01	01	H0712_005_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0712	005	0	1	01	01	H0712_005_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H0712	005	0	1	01	01	H0712_005_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H0712	005	0	1	01	01	H0712_005_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00			
H0712	018	0	1	02	01	H0712_018_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H0712	018	0	1	02	01	H0712_018_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H0712	018	0	1	02	01	H0712_018_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	59.00	177.00								59.00			177.00								59.00			
H0712	018	0	1	02	01	H0712_018_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00			
H0752	002	0	1	01	01	H0752_002_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H0752	002	0	1	01	01	H0752_002_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H0752	002	0	1	01	01	H0752_002_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H0752	002	0	1	01	01	H0752_002_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H0755	001	0	1	01	01	H0755_001_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0755	001	0	1	01	01	H0755_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																						2		
H0755	001	0	1	01	01	H0755_001_0	5	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0755	001	0	1	01	01	H0755_001_0	5	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0755	001	0	1	01	01	H0755_001_0	5	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0755	001	0	1	01	01	H0755_001_0	5	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00	1	1	
H0755	001	0	1	01	01	H0755_001_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0755	001	0	1	01	01	H0755_001_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H0755	001	0	1	01	01	H0755_001_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H0755	001	0	1	01	01	H0755_001_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00			
H0755	020	0	1	02	01	H0755_020_0	7	2	4	3	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H0755	020	0	1	02	01	H0755_020_0	7	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0755	020	0	1	02	01	H0755_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																						2		
H0755	020	0	1	02	01	H0755_020_0	7	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00			
H0755	020	0	1	02	01	H0755_020_0	7	1	4	3	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00	1	1	
H0755	020	0	1	02	01	H0755_020_0	7	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H0755	020	0	1	02	01	H0755_020_0	7	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0755	020	0	1	02	01	H0755_020_0	7	4	4	3	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable																								Tier 4 Injectable		Tier 4 Injectable																						Tier 4 Injectable																						2		
H0755	020	0	1	02	01	H0755_020_0	7	3	4	3	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred																								Tier 3 Non-Preferred		Tier 3 Non-Preferred																						Tier 3 Non-Preferred																						2		
H0755	020	0	1	02	01	H0755_020_0	7	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H0755	022	0	1	01	01	H0755_022_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00			
H0755	022	0	1	01	01	H0755_022_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H0755	022	0	1	01	01	H0755_022_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H0755	022	0	1	01	01	H0755_022_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0755	022	0	1	01	01	H0755_022_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0755	028	0	1	01	01	H0755_028_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H0755	028	0	1	01	01	H0755_028_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00			
H0755	028	0	1	01	01	H0755_028_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0755	028	0	1	01	01	H0755_028_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0755	028	0	1	01	01	H0755_028_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H0755	029	0	1	02	01	H0755_029_0	7	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H0755	029	0	1	02	01	H0755_029_0	7	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H0755	029	0	1	02	01	H0755_029_0	7	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H0755	029	0	1	02	01	H0755_029_0	7	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H0755	029	0	1	02	01	H0755_029_0	7	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	8.00	24.00	16.00							8.00					8.00	16.00	16.00	8.00	24.00	16.00	8.00			
H0806	001	0	1	02	01	H0806_001_0	10	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00			27.00								9.00			
H0806	001	0	1	02	01	H0806_001_0	10	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H0806	001	0	1	02	01	H0806_001_0	10	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H0806	001	0	1	02	01	H0806_001_0	10	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	27.00	81.00								27.00			81.00								27.00			
H0901	004	0	1	01	01	H0901_004_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H0901	004	0	1	01	01	H0901_004_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H0901	004	0	1	01	01	H0901_004_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H0901	004	0	1	01	01	H0901_004_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H0901	004	0	1	01	01	H0901_004_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H0901	007	0	1	01	01	H0901_007_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																						2		
H0901	007	0	1	01	01	H0901_007_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H0901	007	0	1	01	01	H0901_007_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H0901	007	0	1	01	01	H0901_007_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H0901	007	0	1	01	01	H0901_007_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H0901	007	0	1	01	01	H0901_007_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H0901	007	0	1	01	01	H0901_007_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H0901	007	0	1	01	01	H0901_007_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H0901	007	0	1	01	01	H0901_007_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H0908	001	0	1	01	01	H0908_001_0	8	4	4	1	Injectables	000001	1	2	1	Injectables	111000000001010000000	30	90									29		90								31	2	Injectables	2	Injectables																						Injectables	95.00	95.00									95.00		95.00								95.00			
H0908	001	0	1	01	01	H0908_001_0	8	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	30	90									29		90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	95.00									95.00		95.00								95.00			
H0908	001	0	1	01	01	H0908_001_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	45.00									45.00		45.00								45.00			
H0908	001	0	1	01	01	H0908_001_0	8	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	2	Generic																						Generic	0.00	0.00									0.00		0.00								0.00			
H0913	002	0	1	01	01	H0913_002_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H0913	002	0	1	01	01	H0913_002_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00			
H0913	002	0	1	01	01	H0913_002_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0913	003	0	1	01	01	H0913_003_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H0913	003	0	1	01	01	H0913_003_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	68.00	204.00								68.00			204.00								68.00			
H0913	003	0	1	01	01	H0913_003_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0913	003	0	1	01	01	H0913_003_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H0913	008	0	1	01	01	H0913_008_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H0913	008	0	1	01	01	H0913_008_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00			
H0913	008	0	1	01	01	H0913_008_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H0913	008	0	1	01	01	H0913_008_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	76.00	228.00								76.00			228.00								76.00			
H0913	009	0	1	01	01	H0913_009_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H0913	009	0	1	01	01	H0913_009_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00			
H0913	009	0	1	01	01	H0913_009_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H0913	009	0	1	01	01	H0913_009_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H0979	005	0	1	09	04	H0979_005_0	8	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H0979	005	0	1	09	04	H0979_005_0	8	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	45.00	135.00								45.00		45.00	90.00								45.00			
H0979	005	0	1	09	04	H0979_005_0	8	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00		75.00	150.00								75.00			
H0979	005	0	1	09	04	H0979_005_0	8	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H0979	007	0	1	09	04	H0979_007_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H0979	007	0	1	09	04	H0979_007_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H0979	007	0	1	09	04	H0979_007_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H0979	007	0	1	09	04	H0979_007_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H0979	022	0	1	09	04	H0979_022_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	45.00	135.00								45.00		45.00	90.00								45.00			
H0979	022	0	1	09	04	H0979_022_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00		75.00	150.00								75.00			
H0979	022	0	1	09	04	H0979_022_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H0979	022	0	1	09	04	H0979_022_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H1013	011	0	1	01	01	H1013_011_0	8	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H1013	011	0	1	01	01	H1013_011_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00			
H1013	011	0	1	01	01	H1013_011_0	8	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H1013	011	0	1	01	01	H1013_011_0	8	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H1013	011	0	1	01	01	H1013_011_0	8	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H1013	011	0	1	01	01	H1013_011_0	8	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1013	011	0	1	01	01	H1013_011_0	8	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1013	011	0	1	01	01	H1013_011_0	8	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H1013	021	0	1	02	01	H1013_021_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1013	021	0	1	02	01	H1013_021_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1013	021	0	1	02	01	H1013_021_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H1013	021	0	1	02	01	H1013_021_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H1013	021	0	1	02	01	H1013_021_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H1013	021	0	1	02	01	H1013_021_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H1013	021	0	1	02	01	H1013_021_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00			40.00								20.00			
H1013	021	0	1	02	01	H1013_021_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H1013	024	0	1	01	01	H1013_024_0	7	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	25									25											25	Specialty Drugs																								
H1013	024	0	1	01	01	H1013_024_0	7	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H1013	024	0	1	01	01	H1013_024_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1013	024	0	1	01	01	H1013_024_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H1013	024	0	1	01	01	H1013_024_0	7	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H1013	024	0	1	01	01	H1013_024_0	7	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H1013	024	0	1	01	01	H1013_024_0	7	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1013	024	0	1	01	01	H1013_024_0	7	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00			231.00								77.00			
H1016	001	0	1	01	01	H1016_001_0	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1016	001	0	1	01	01	H1016_001_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	20.00	60.00								20.00			60.00								20.00			
H1016	001	0	1	01	01	H1016_001_0	7	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1016	001	0	1	01	01	H1016_001_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1016	001	0	1	01	01	H1016_001_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1016	001	0	1	01	01	H1016_001_0	7	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H1016	001	0	1	01	01	H1016_001_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	25									25											25	Tier 4																								
H1016	001	0	1	01	01	H1016_001_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	50.00	150.00								50.00			150.00								50.00			
H1016	002	0	1	01	01	H1016_002_0	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00								7.00			21.00								7.00			
H1016	002	0	1	01	01	H1016_002_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1016	002	0	1	01	01	H1016_002_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1016	002	0	1	01	01	H1016_002_0	7	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00								7.00			21.00								7.00	1	1	
H1016	002	0	1	01	01	H1016_002_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	33									33											33	Tier 4																								
H1016	002	0	1	01	01	H1016_002_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
H1016	002	0	1	01	01	H1016_002_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1016	002	0	1	01	01	H1016_002_0	7	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1019	001	0	1	01	01	H1019_001_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00			
H1019	001	0	1	01	01	H1019_001_0	8	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	001	0	1	01	01	H1019_001_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H1019	001	0	1	01	01	H1019_001_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	001	0	1	01	01	H1019_001_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00	1	2	10000000
H1019	001	0	1	01	01	H1019_001_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	001	0	1	01	01	H1019_001_0	8	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1019	001	0	1	01	01	H1019_001_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	002	0	1	01	01	H1019_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	002	0	1	01	01	H1019_002_0	5	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	002	0	1	01	01	H1019_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	002	0	1	01	01	H1019_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H1019	002	0	1	01	01	H1019_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	002	0	1	01	01	H1019_002_0	5	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1019	002	0	1	01	01	H1019_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10000000
H1019	002	0	1	01	01	H1019_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	004	0	1	01	01	H1019_004_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	004	0	1	01	01	H1019_004_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00	1	2	10000000
H1019	004	0	1	01	01	H1019_004_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	004	0	1	01	01	H1019_004_0	8	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1019	004	0	1	01	01	H1019_004_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	004	0	1	01	01	H1019_004_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00					30.00	75.00		30.00	90.00		30.00			
H1019	004	0	1	01	01	H1019_004_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00			
H1019	004	0	1	01	01	H1019_004_0	8	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	005	0	1	01	01	H1019_005_0	10	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	005	0	1	01	01	H1019_005_0	10	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1019	005	0	1	01	01	H1019_005_0	10	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	005	0	1	01	01	H1019_005_0	10	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	005	0	1	01	01	H1019_005_0	10	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1019	005	0	1	01	01	H1019_005_0	10	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	005	0	1	01	01	H1019_005_0	10	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	005	0	1	01	01	H1019_005_0	10	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	006	0	1	01	01	H1019_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10000000
H1019	006	0	1	01	01	H1019_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	006	0	1	01	01	H1019_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	006	0	1	01	01	H1019_006_0	4	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1019	006	0	1	01	01	H1019_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	006	0	1	01	01	H1019_006_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H1019	006	0	1	01	01	H1019_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	006	0	1	01	01	H1019_006_0	4	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	010	0	1	01	01	H1019_010_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	010	0	1	01	01	H1019_010_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	010	0	1	01	01	H1019_010_0	8	1	4	1	Preferred Generic/Value Brand	011010	1	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1019	010	0	1	01	01	H1019_010_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1019	010	0	1	01	01	H1019_010_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	010	0	1	01	01	H1019_010_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	010	0	1	01	01	H1019_010_0	8	1	4	3	Preferred Generic/Value Brand	011010	1	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	1	
H1019	010	0	1	01	01	H1019_010_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	011	0	1	01	01	H1019_011_0	9	1	4	1	Preferred Generic/Value Brand	011010	1	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1019	011	0	1	01	01	H1019_011_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	011	0	1	01	01	H1019_011_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1019	011	0	1	01	01	H1019_011_0	9	1	4	3	Preferred Generic/Value Brand	011010	1	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	10001000
H1019	011	0	1	01	01	H1019_011_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	011	0	1	01	01	H1019_011_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	011	0	1	01	01	H1019_011_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1019	011	0	1	01	01	H1019_011_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	014	0	1	01	01	H1019_014_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								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	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00			
H1019	014	0	1	01	01	H1019_014_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	014	0	1	01	01	H1019_014_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	014	0	1	01	01	H1019_014_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1019	014	0	1	01	01	H1019_014_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00	1	2	10001000
H1019	014	0	1	01	01	H1019_014_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	014	0	1	01	01	H1019_014_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	023	0	1	01	01	H1019_023_0	6	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	023	0	1	01	01	H1019_023_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00								78.00					78.00	195.00		78.00	234.00		78.00			
H1019	023	0	1	01	01	H1019_023_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	023	0	1	01	01	H1019_023_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00			
H1019	024	0	1	01	01	H1019_024_0	5	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	024	0	1	01	01	H1019_024_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1019	024	0	1	01	01	H1019_024_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	81.00	243.00								81.00					81.00	202.50		81.00	243.00		81.00			
H1019	024	0	1	01	01	H1019_024_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	025	0	1	01	01	H1019_025_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	025	0	1	01	01	H1019_025_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1019	025	0	1	01	01	H1019_025_0	6	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	025	0	1	01	01	H1019_025_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	32.00	96.00								32.00					32.00	80.00		32.00	96.00		32.00			
H1019	026	0	1	01	01	H1019_026_0	6	1	4	1	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	026	0	1	01	01	H1019_026_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H1019	026	0	1	01	01	H1019_026_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1019	026	0	1	01	01	H1019_026_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	027	0	1	01	01	H1019_027_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	100110	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1019	027	0	1	01	01	H1019_027_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	027	0	1	01	01	H1019_027_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	027	0	1	01	01	H1019_027_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1019	027	0	1	01	01	H1019_027_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	027	0	1	01	01	H1019_027_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	027	0	1	01	01	H1019_027_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1019	027	0	1	01	01	H1019_027_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	100110	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1019	028	0	1	01	01	H1019_028_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	028	0	1	01	01	H1019_028_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00					77.00	192.50		77.00	231.00		77.00			
H1019	028	0	1	01	01	H1019_028_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	32.00	96.00								32.00					32.00	80.00		32.00	96.00		32.00			
H1019	028	0	1	01	01	H1019_028_0	6	1	4	1	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	032	0	1	01	01	H1019_032_0	5	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	1	
H1019	032	0	1	01	01	H1019_032_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	032	0	1	01	01	H1019_032_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H1019	032	0	1	01	01	H1019_032_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00			
H1019	032	0	1	01	01	H1019_032_0	5	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	032	0	1	01	01	H1019_032_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	032	0	1	01	01	H1019_032_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H1019	032	0	1	01	01	H1019_032_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00	1	2	10001000
H1019	035	0	1	01	01	H1019_035_0	5	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1019	035	0	1	01	01	H1019_035_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	035	0	1	01	01	H1019_035_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00			
H1019	035	0	1	01	01	H1019_035_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	035	0	1	01	01	H1019_035_0	5	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								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	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1019	035	0	1	01	01	H1019_035_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00	1	2	10000000
H1019	035	0	1	01	01	H1019_035_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	043	0	1	01	01	H1019_043_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1019	043	0	1	01	01	H1019_043_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H1019	043	0	1	01	01	H1019_043_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	043	0	1	01	01	H1019_043_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	043	0	1	01	01	H1019_043_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1019	043	0	1	01	01	H1019_043_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00	1	2	10001000
H1019	043	0	1	01	01	H1019_043_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	043	0	1	01	01	H1019_043_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	044	0	1	01	01	H1019_044_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1019	044	0	1	01	01	H1019_044_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1019	044	0	1	01	01	H1019_044_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1019	044	0	1	01	01	H1019_044_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1019	044	0	1	01	01	H1019_044_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1019	044	0	1	01	01	H1019_044_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1019	044	0	1	01	01	H1019_044_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1019	044	0	1	01	01	H1019_044_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1019	045	0	1	01	01	H1019_045_0	7	4	3	1	Specialty	110110		1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	045	0	1	01	01	H1019_045_0	7	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1019	045	0	1	01	01	H1019_045_0	7	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	34.00	102.00								34.00					34.00	85.00		34.00	102.00		34.00			
H1019	045	0	1	01	01	H1019_045_0	7	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	046	0	1	01	01	H1019_046_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1019	046	0	1	01	01	H1019_046_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H1019	046	0	1	01	01	H1019_046_0	6	1	4	1	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	046	0	1	01	01	H1019_046_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	047	0	1	01	01	H1019_047_0	6	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	047	0	1	01	01	H1019_047_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	39.00	117.00								39.00					39.00	97.50		39.00	117.00		39.00			
H1019	047	0	1	01	01	H1019_047_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00								78.00					78.00	195.00		78.00	234.00		78.00			
H1019	047	0	1	01	01	H1019_047_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	048	0	1	01	01	H1019_048_0	6	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	048	0	1	01	01	H1019_048_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1019	048	0	1	01	01	H1019_048_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	81.00	243.00								81.00					81.00	202.50		81.00	243.00		81.00			
H1019	048	0	1	01	01	H1019_048_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	049	0	1	01	01	H1019_049_0	6	1	4	1	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	049	0	1	01	01	H1019_049_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	32.00	96.00								32.00					32.00	80.00		32.00	96.00		32.00			
H1019	049	0	1	01	01	H1019_049_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1019	049	0	1	01	01	H1019_049_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00					77.00	192.50		77.00	231.00		77.00			
H1019	050	0	1	01	01	H1019_050_0	6	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1019	050	0	1	01	01	H1019_050_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1019	050	0	1	01	01	H1019_050_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	32.00	96.00								32.00					32.00	80.00		32.00	96.00		32.00			
H1019	050	0	1	01	01	H1019_050_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1026	001	0	1	01	01	H1026_001_0	8	3	4	1	Tier 3 - Covered Brand	100000	1	2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H1026	001	0	1	01	01	H1026_001_0	8	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H1026	001	0	1	01	01	H1026_001_0	8	1	4	1	Tier 1 - Covered Generic	010000	1	2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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	8	1	4	3	Tier 1 - Covered Generic	010000	1	2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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	1	1	
H1026	001	0	1	01	01	H1026_001_0	8	4	4	3	Tier S - Covered Specialty	110001	1	1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																						1	2	01000000
H1026	001	0	1	01	01	H1026_001_0	8	4	4	1	Tier S - Covered Specialty	110001	1	1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	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	8	3	4	3	Tier 3 - Covered Brand	100000	1	2	1	Tier 3 - Covered Brand																								Tier 3 - Covered Brand		Tier 3 - Covered Brand																						Tier 3 - Covered Brand																						2		
H1026	001	0	1	01	01	H1026_001_0	8	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																						2		
H1026	033	0	1	01	01	H1026_033_0	6	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
H1026	033	0	1	01	01	H1026_033_0	6	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	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	033	0	1	01	01	H1026_033_0	6	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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	033	0	1	01	01	H1026_033_0	6	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	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			
H1026	038	0	1	01	01	H1026_038_0	6	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	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	6	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
H1026	038	0	1	01	01	H1026_038_0	6	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	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			
H1026	038	0	1	01	01	H1026_038_0	6	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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	040	0	1	01	01	H1026_040_0	6	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	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			
H1026	040	0	1	01	01	H1026_040_0	6	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	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	040	0	1	01	01	H1026_040_0	6	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
H1026	040	0	1	01	01	H1026_040_0	6	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
H1032	002	0	1	02	01	H1032_002_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H1032	002	0	1	02	01	H1032_002_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	002	0	1	02	01	H1032_002_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			75.00								25.00			
H1032	002	0	1	02	01	H1032_002_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1032	008	0	1	01	01	H1032_008_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00			90.00								30.00			
H1032	008	0	1	01	01	H1032_008_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1032	008	0	1	01	01	H1032_008_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00			0.00								0.00			
H1032	008	0	1	01	01	H1032_008_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	012	0	1	02	01	H1032_012_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1032	012	0	1	02	01	H1032_012_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00			
H1032	012	0	1	02	01	H1032_012_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	014	0	1	02	01	H1032_014_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	014	0	1	02	01	H1032_014_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1032	014	0	1	02	01	H1032_014_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1032	014	0	1	02	01	H1032_014_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	025	0	1	02	01	H1032_025_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	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	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	032	0	1	02	01	H1032_032_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	032	0	1	02	01	H1032_032_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H1032	032	0	1	02	01	H1032_032_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	032	0	1	02	01	H1032_032_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1032	035	0	1	02	01	H1032_035_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1032	035	0	1	02	01	H1032_035_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	035	0	1	02	01	H1032_035_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1032	040	0	1	01	01	H1032_040_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	040	0	1	01	01	H1032_040_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1032	040	0	1	01	01	H1032_040_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1032	040	0	1	01	01	H1032_040_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H1032	061	0	1	02	01	H1032_061_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1032	061	0	1	02	01	H1032_061_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00			
H1032	061	0	1	02	01	H1032_061_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	073	0	1	02	01	H1032_073_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	073	0	1	02	01	H1032_073_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1032	073	0	1	02	01	H1032_073_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	079	0	1	01	01	H1032_079_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H1032	079	0	1	01	01	H1032_079_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	079	0	1	01	01	H1032_079_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	079	0	1	01	01	H1032_079_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H1032	085	0	1	01	01	H1032_085_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00			
H1032	085	0	1	01	01	H1032_085_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	085	0	1	01	01	H1032_085_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1032	091	0	1	02	01	H1032_091_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	091	0	1	02	01	H1032_091_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	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	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1032	101	0	1	02	01	H1032_101_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1032	101	0	1	02	01	H1032_101_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1032	101	0	1	02	01	H1032_101_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
H1032	101	0	1	02	01	H1032_101_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	106	0	1	02	01	H1032_106_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00			
H1032	106	0	1	02	01	H1032_106_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00			
H1032	106	0	1	02	01	H1032_106_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1032	106	0	1	02	01	H1032_106_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
H1032	107	0	1	01	01	H1032_107_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	107	0	1	01	01	H1032_107_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1032	107	0	1	01	01	H1032_107_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	72.00	216.00								72.00			216.00								72.00			
H1032	107	0	1	01	01	H1032_107_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	113	0	1	02	01	H1032_113_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1032	113	0	1	02	01	H1032_113_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1032	123	0	1	01	01	H1032_123_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00			
H1032	123	0	1	01	01	H1032_123_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1032	123	0	1	01	01	H1032_123_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H1032	123	0	1	01	01	H1032_123_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	124	0	1	01	01	H1032_124_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	124	0	1	01	01	H1032_124_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1032	124	0	1	01	01	H1032_124_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H1032	131	0	1	02	01	H1032_131_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1032	131	0	1	02	01	H1032_131_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	132	0	1	02	01	H1032_132_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1032	132	0	1	02	01	H1032_132_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H1032	132	0	1	02	01	H1032_132_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1032	133	0	1	02	01	H1032_133_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1032	133	0	1	02	01	H1032_133_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1035	002	0	1	02	01	H1035_002_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1035	002	0	1	02	01	H1035_002_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1035	002	0	1	02	01	H1035_002_0	5	6	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H1035	002	0	1	02	01	H1035_002_0	5	7	4	3	Part D Excluded Drugs	010000	2	2	2	Part D Excluded Drugs	100011011010010000000				31	93		31	93		31			93								31	2	Part D Excluded Drugs	2	Part D Excluded Drugs																						Part D Excluded Drugs				10.00	30.00		15.00	45.00		15.00			27.00								15.00	1	1	
H1035	002	0	1	02	01	H1035_002_0	5	5	4	3	Injectables	010010	1	2	2	Injectables																								Injectables		Injectables																						Injectables																						2		
H1035	002	0	1	02	01	H1035_002_0	5	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	100011011010010000000				31	93		31	93		31			93								31	2	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic				6.00	18.00		13.00	39.00		13.00			15.00								13.00	1	1	
H1035	002	0	1	02	01	H1035_002_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	100011011010010000000				31	93		31	93		31			93								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		11.00	33.00		11.00			9.00								11.00	1	1	
H1035	002	0	1	02	01	H1035_002_0	5	7	4	1	Part D Excluded Drugs	010000	2	2	2	Part D Excluded Drugs	100011011010010000000				31	93		31	93		31			93								31	2	Part D Excluded Drugs	2	Part D Excluded Drugs																						Part D Excluded Drugs				10.00	30.00		15.00	45.00		15.00			27.00								15.00			
H1035	002	0	1	02	01	H1035_002_0	5	6	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	100011011010010000000				31	93		31	93		31			93								31	2	Specialty Drugs	1	Specialty Drugs				33	33		33	33		33			33								33	Specialty Drugs																								
H1035	002	0	1	02	01	H1035_002_0	5	5	4	1	Injectables	010010	1	2	2	Injectables	100011011010010000000				31	93		31	93		31			93								31	2	Injectables	1	Injectables				25	25		25	25		25			25								25	Injectables																								
H1035	002	0	1	02	01	H1035_002_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	100011011010010000000				31	93		31	93		31			93								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		11.00	33.00		11.00			9.00								11.00			
H1035	002	0	1	02	01	H1035_002_0	5	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	100011011010010000000				31	93		31	93		31			93								31	2	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic				6.00	18.00		13.00	39.00		13.00			15.00								13.00			
H1035	002	0	1	02	01	H1035_002_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010010000000				31	93		31	93		31			93								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				40.00	120.00		50.00	150.00		50.00			117.00								50.00			
H1035	002	0	1	02	01	H1035_002_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	100011011010010000000				31	93		31	93		31			93								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				70.00	210.00		80.00	240.00		80.00			207.00								80.00			
H1035	006	0	1	02	01	H1035_006_0	5	6	4	1	Specialty	000010	1	1	2	Specialty	100011011010010000000				31	93		31	93		31			93								31	2	Specialty	1	Specialty				29	29		29	29		29			29								29	Specialty																								
H1035	006	0	1	02	01	H1035_006_0	5	5	4	1	Injectables	010010	1	2	2	Injectables	100011011010010000000				31	93		31	93		31			93								31	2	Injectables	1	Injectables				25	25		25	25		25			25								25	Injectables																								
H1035	006	0	1	02	01	H1035_006_0	5	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	100011011010010000000				31	93		31	93		31			93								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				70.00	210.00		80.00	240.00		80.00			207.00								80.00			
H1035	006	0	1	02	01	H1035_006_0	5	3	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	100011011010010000000				31	93		31	93		31			93								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				40.00	120.00		50.00	150.00		50.00			117.00								50.00			
H1035	006	0	1	02	01	H1035_006_0	5	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	100011011010010000000				31	93		31	93		31			93								31	2	Non-Preferred Generic	1	Non-Preferred Generic				20	20		30	30		30			20								30	Non-Preferred Generic																								
H1035	006	0	1	02	01	H1035_006_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	100011011010010000000				31	93		31	93		31			93								31	2	Preferred Generic	1	Preferred Generic				20	20		30	30		30			20								30	Preferred Generic																								
H1036	011	0	1	01	01	H1036_011_0	3	1	4	3	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	011	0	1	01	01	H1036_011_0	3	1	4	1	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1036	011	0	1	01	01	H1036_011_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00					85.00	212.50		85.00	255.00		85.00	1	2	10000000
H1036	011	0	1	01	01	H1036_011_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	011	0	1	01	01	H1036_011_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00	1	2	10001000
H1036	011	0	1	01	01	H1036_011_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H1036	011	0	1	01	01	H1036_011_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00					85.00	212.50		85.00	255.00		85.00			
H1036	011	0	1	01	01	H1036_011_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	025	0	1	01	01	H1036_025_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	025	0	1	01	01	H1036_025_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00	1	2	10000000
H1036	025	0	1	01	01	H1036_025_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	025	0	1	01	01	H1036_025_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1036	025	0	1	01	01	H1036_025_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00			
H1036	025	0	1	01	01	H1036_025_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	034	0	1	01	01	H1036_034_0	3	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1036	034	0	1	01	01	H1036_034_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1036	034	0	1	01	01	H1036_034_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H1036	034	0	1	01	01	H1036_034_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	034	0	1	01	01	H1036_034_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	034	0	1	01	01	H1036_034_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1036	034	0	1	01	01	H1036_034_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00			
H1036	034	0	1	01	01	H1036_034_0	3	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1036	035	0	1	01	01	H1036_035_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	035	0	1	01	01	H1036_035_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1036	035	0	1	01	01	H1036_035_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1036	035	0	1	01	01	H1036_035_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	035	0	1	01	01	H1036_035_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	035	0	1	01	01	H1036_035_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1036	035	0	1	01	01	H1036_035_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1036	040	0	1	01	01	H1036_040_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	040	0	1	01	01	H1036_040_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H1036	040	0	1	01	01	H1036_040_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	4.00	12.00								4.00					4.00	10.00		4.00	12.00		4.00			
H1036	040	0	1	01	01	H1036_040_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	040	0	1	01	01	H1036_040_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	4.00	12.00								4.00					4.00	10.00		4.00	12.00		4.00	1	2	10001000
H1036	040	0	1	01	01	H1036_040_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H1036	040	0	1	01	01	H1036_040_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	040	0	1	01	01	H1036_040_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	044	0	1	01	01	H1036_044_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1036	044	0	1	01	01	H1036_044_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	044	0	1	01	01	H1036_044_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1036	044	0	1	01	01	H1036_044_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1036	044	0	1	01	01	H1036_044_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	044	0	1	01	01	H1036_044_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	047	0	1	01	01	H1036_047_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	047	0	1	01	01	H1036_047_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1036	047	0	1	01	01	H1036_047_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1036	047	0	1	01	01	H1036_047_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	047	0	1	01	01	H1036_047_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1036	047	0	1	01	01	H1036_047_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	047	0	1	01	01	H1036_047_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1036	047	0	1	01	01	H1036_047_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	052	0	1	01	01	H1036_052_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00			
H1036	052	0	1	01	01	H1036_052_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	052	0	1	01	01	H1036_052_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	052	0	1	01	01	H1036_052_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00	1	2	10000000
H1036	052	0	1	01	01	H1036_052_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	052	0	1	01	01	H1036_052_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1036	054	0	1	01	01	H1036_054_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1036	054	0	1	01	01	H1036_054_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10000000
H1036	054	0	1	01	01	H1036_054_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	054	0	1	01	01	H1036_054_0	4	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H1036	054	0	1	01	01	H1036_054_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	054	0	1	01	01	H1036_054_0	4	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1036	062	0	1	01	01	H1036_062_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	062	0	1	01	01	H1036_062_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1036	062	0	1	01	01	H1036_062_0	4	1	4	1	Preferred Generic/Value Brand	011010	1	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	062	0	1	01	01	H1036_062_0	4	1	4	3	Preferred Generic/Value Brand	011010	1	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	1	
H1036	062	0	1	01	01	H1036_062_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1036	062	0	1	01	01	H1036_062_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1036	062	0	1	01	01	H1036_062_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	065	0	1	01	01	H1036_065_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H1036	065	0	1	01	01	H1036_065_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00			
H1036	065	0	1	01	01	H1036_065_0	4	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	065	0	1	01	01	H1036_065_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	065	0	1	01	01	H1036_065_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00	1	2	10000000
H1036	065	0	1	01	01	H1036_065_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
H1036	065	0	1	01	01	H1036_065_0	4	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1036	067	0	1	01	01	H1036_067_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	4.00	12.00								4.00					4.00	10.00		4.00	12.00		4.00			
H1036	067	0	1	01	01	H1036_067_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00			
H1036	067	0	1	01	01	H1036_067_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00	1	2	10000000
H1036	067	0	1	01	01	H1036_067_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	4.00	12.00								4.00					4.00	10.00		4.00	12.00		4.00	1	2	10001000
H1036	067	0	1	01	01	H1036_067_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	067	0	1	01	01	H1036_067_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	067	0	1	01	01	H1036_067_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	068	0	1	01	01	H1036_068_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	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	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	068	0	1	01	01	H1036_068_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1036	068	0	1	01	01	H1036_068_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1036	068	0	1	01	01	H1036_068_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1036	068	0	1	01	01	H1036_068_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	068	0	1	01	01	H1036_068_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	074	0	1	01	01	H1036_074_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00			
H1036	074	0	1	01	01	H1036_074_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	10.00	30.00								10.00					10.00	25.00		10.00	30.00		10.00	1	2	10001000
H1036	074	0	1	01	01	H1036_074_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00	1	2	10000000
H1036	074	0	1	01	01	H1036_074_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	074	0	1	01	01	H1036_074_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1036	074	0	1	01	01	H1036_074_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	074	0	1	01	01	H1036_074_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00			
H1036	074	0	1	01	01	H1036_074_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	73.00	219.00								73.00					73.00	182.50		73.00	219.00		73.00			
H1036	077	0	1	01	01	H1036_077_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1036	077	0	1	01	01	H1036_077_0	4	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	081	0	1	01	01	H1036_081_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	081	0	1	01	01	H1036_081_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1036	081	0	1	01	01	H1036_081_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1036	081	0	1	01	01	H1036_081_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1036	081	0	1	01	01	H1036_081_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	081	0	1	01	01	H1036_081_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1036	102	0	1	01	01	H1036_102_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00			
H1036	102	0	1	01	01	H1036_102_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	84.00	252.00								84.00					84.00	210.00		84.00	252.00		84.00			
H1036	102	0	1	01	01	H1036_102_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1036	102	0	1	01	01	H1036_102_0	3	1	4	1	Preferred Generic	011000	3	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	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	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1036	103	0	1	01	01	H1036_103_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	87.00	261.00								87.00					87.00	217.50		87.00	261.00		87.00			
H1036	103	0	1	01	01	H1036_103_0	3	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1036	104	0	1	01	01	H1036_104_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1036	104	0	1	01	01	H1036_104_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1036	104	0	1	01	01	H1036_104_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	69.00	207.00								69.00					69.00	172.50		69.00	207.00		69.00			
H1036	104	0	1	01	01	H1036_104_0	3	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00	1	2	10000000
H1036	121	0	1	01	01	H1036_121_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	121	0	1	01	01	H1036_121_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00	1	2	10001000
H1036	121	0	1	01	01	H1036_121_0	3	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1036	121	0	1	01	01	H1036_121_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	121	0	1	01	01	H1036_121_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H1036	121	0	1	01	01	H1036_121_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00			
H1036	121	0	1	01	01	H1036_121_0	3	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	10001000
H1036	125	0	1	01	01	H1036_125_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00	1	2	10000000
H1036	125	0	1	01	01	H1036_125_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	125	0	1	01	01	H1036_125_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	125	0	1	01	01	H1036_125_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00			
H1036	125	0	1	01	01	H1036_125_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	2	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	2	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	1	
H1036	130	0	1	01	01	H1036_130_0	3	1	4	1	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value 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	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1036	130	0	1	01	01	H1036_130_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1036	130	0	1	01	01	H1036_130_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1036	130	0	1	01	01	H1036_130_0	3	1	4	3	Preferred Generic/Value Brand	011010	3	2	2	Preferred Generic/Value Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic/Value Brand	2	Preferred Generic/Value Brand																						Preferred Generic/Value Brand	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	1	
H1036	130	0	1	01	01	H1036_130_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1036	130	0	1	01	01	H1036_130_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1036	130	0	1	01	01	H1036_130_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1045	001	0	1	02	01	H1045_001_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	001	0	1	02	01	H1045_001_0	6	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	001	0	1	02	01	H1045_001_0	6	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	2	Tier 3																						Tier 3	25.00	75.00								25.00		25.00	50.00								25.00			
H1045	001	0	1	02	01	H1045_001_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	20	20								20		20	20								20	Tier 4																								
H1045	001	0	1	02	01	H1045_001_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	001	0	1	02	01	H1045_001_0	6	2	4	3	Tier 2	010001	3	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1045	001	0	1	02	01	H1045_001_0	6	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1045	001	0	1	02	01	H1045_001_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1045	005	0	1	01	01	H1045_005_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1045	005	0	1	01	01	H1045_005_0	6	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1045	005	0	1	01	01	H1045_005_0	6	2	4	3	Tier 2	010001	3	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1045	005	0	1	01	01	H1045_005_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	005	0	1	01	01	H1045_005_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H1045	005	0	1	01	01	H1045_005_0	6	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	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	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	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	6	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	50.00								25.00			
H1045	008	0	1	01	01	H1045_008_0	5	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	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	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	20	20								20		20	20								20	Tier 4																								
H1045	008	0	1	01	01	H1045_008_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	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	5	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 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	5	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	008	0	1	01	01	H1045_008_0	5	2	4	3	Tier 2	010001	3	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1045	008	0	1	01	01	H1045_008_0	5	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1045	008	0	1	01	01	H1045_008_0	5	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1045	010	0	1	02	01	H1045_010_0	9	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00		25.00	50.00								25.00			
H1045	010	0	1	02	01	H1045_010_0	9	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	2	Tier 3																						Tier 3	50.00	150.00								50.00		50.00	100.00								50.00			
H1045	010	0	1	02	01	H1045_010_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H1045	010	0	1	02	01	H1045_010_0	9	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	012	0	1	01	01	H1045_012_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	012	0	1	01	01	H1045_012_0	6	2	4	3	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	012	0	1	01	01	H1045_012_0	6	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1045	012	0	1	01	01	H1045_012_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	012	0	1	01	01	H1045_012_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1045	012	0	1	01	01	H1045_012_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	25	25								25		25	25								25	Tier 4																								
H1045	012	0	1	01	01	H1045_012_0	6	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	2	Tier 3																						Tier 3	5.00	15.00								5.00		5.00	10.00								5.00			
H1045	012	0	1	01	01	H1045_012_0	6	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	016	0	1	01	01	H1045_016_0	5	2	4	3	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	016	0	1	01	01	H1045_016_0	5	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	016	0	1	01	01	H1045_016_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	20	20								20		20	20								20	Tier 4																								
H1045	016	0	1	01	01	H1045_016_0	5	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00			
H1045	016	0	1	01	01	H1045_016_0	5	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	016	0	1	01	01	H1045_016_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	016	0	1	01	01	H1045_016_0	5	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1045	016	0	1	01	01	H1045_016_0	5	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1045	017	0	1	02	01	H1045_017_0	5	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00		70.00	210.00								70.00			
H1045	017	0	1	02	01	H1045_017_0	5	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00		35.00	105.00								35.00			
H1045	017	0	1	02	01	H1045_017_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00								7.00		7.00	0.00								7.00			
H1045	017	0	1	02	01	H1045_017_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H1045	018	0	1	01	01	H1045_018_0	4	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1045	018	0	1	01	01	H1045_018_0	4	2	4	3	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	018	0	1	01	01	H1045_018_0	4	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1045	018	0	1	01	01	H1045_018_0	4	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1045	018	0	1	01	01	H1045_018_0	4	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								34	1	Tier 3	2	Tier 3																						Tier 3	20.00	60.00								20.00		20.00	40.00								20.00			
H1045	018	0	1	01	01	H1045_018_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								34	2	Tier 4	1	Tier 4	20	20								20		20	20								20	Tier 4																								
H1045	018	0	1	01	01	H1045_018_0	4	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								34	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H1045	018	0	1	01	01	H1045_018_0	4	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010110000000	30	90								30		30	90								34	1	Tier 2	2	Tier 2																						Tier 2	0.00	0.00								0.00		0.00	0.00								0.00			
H1076	003	0	1	01	01	H1076_003_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	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	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	40.00								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	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H1076	003	0	1	01	01	H1076_003_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H1076	003	0	1	01	01	H1076_003_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
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																						2		
H1076	003	0	1	01	01	H1076_003_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
H1076	011	0	1	01	01	H1076_011_0	7	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00			
H1076	011	0	1	01	01	H1076_011_0	7	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	25									25											25	Specialty Drugs																								
H1076	011	0	1	01	01	H1076_011_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H1076	011	0	1	01	01	H1076_011_0	7	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H1076	016	0	1	01	01	H1076_016_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H1076	016	0	1	01	01	H1076_016_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1076	016	0	1	01	01	H1076_016_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1076	016	0	1	01	01	H1076_016_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H1076	016	0	1	01	01	H1076_016_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H1076	016	0	1	01	01	H1076_016_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00			
H1076	016	0	1	01	01	H1076_016_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	70.00								35.00			70.00								35.00			
H1076	016	0	1	01	01	H1076_016_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H1080	004	0	1	02	01	H1080_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1080	004	0	1	02	01	H1080_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H1080	004	0	1	02	01	H1080_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1080	004	0	1	02	01	H1080_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1080	042	0	1	01	01	H1080_042_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1080	042	0	1	01	01	H1080_042_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00			
H1080	042	0	1	01	01	H1080_042_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1080	042	0	1	01	01	H1080_042_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1099	001	0	1	02	01	H1099_001_0	6	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	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	6	2	4	1	Tier 2 Generic	010000	1	2	2	Tier 2 Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 Generic	2	Tier 2 Generic																						Tier 2 Generic	10.00	30.00								10.00			20.00								10.00			
H1099	001	0	1	02	01	H1099_001_0	6	4	4	3	Tier 4 Specialty	000010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H1099	001	0	1	02	01	H1099_001_0	6	3	4	3	Tier 3 Brand	000010	1	2	1	Tier 3 Brand																								Tier 3 Brand		Tier 3 Brand																						Tier 3 Brand																						2		
H1099	001	0	1	02	01	H1099_001_0	6	2	4	3	Tier 2 Generic	010000	1	2	2	Tier 2 Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 Generic	2	Tier 2 Generic																						Tier 2 Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H1099	001	0	1	02	01	H1099_001_0	6	1	4	3	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00	1	1	
H1099	001	0	1	02	01	H1099_001_0	6	4	4	1	Tier 4 Specialty	000010	1	1	2	Tier 4 Specialty	111000000010010000000	30	90								30			90								31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																								
H1099	001	0	1	02	01	H1099_001_0	6	3	4	1	Tier 3 Brand	000010	1	2	1	Tier 3 Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Brand	2	Tier 3 Brand																						Tier 3 Brand	50.00	150.00								50.00			100.00								50.00			
H1099	006	0	1	01	01	H1099_006_0	6	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	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	6	3	4	3	Tier 3 Brand	000010	1	2	1	Tier 3 Brand																								Tier 3 Brand		Tier 3 Brand																						Tier 3 Brand																						2		
H1099	006	0	1	01	01	H1099_006_0	6	2	4	3	Tier 2 Generic	010000	1	2	2	Tier 2 Generic																								Tier 2 Generic		Tier 2 Generic																						Tier 2 Generic																						2		
H1099	006	0	1	01	01	H1099_006_0	6	1	4	3	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	2.00	6.00								2.00			10.00								2.00	1	1	
H1099	006	0	1	01	01	H1099_006_0	6	4	4	1	Tier 4 Specialty	000010	1	1	2	Tier 4 Specialty	111000000010010000000	30	90								30			90								31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33			33								33	Tier 4 Specialty																								
H1099	006	0	1	01	01	H1099_006_0	6	3	4	1	Tier 3 Brand	000010	1	2	1	Tier 3 Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Brand	2	Tier 3 Brand																						Tier 3 Brand	50.00	150.00								50.00			100.00								50.00			
H1099	006	0	1	01	01	H1099_006_0	6	2	4	1	Tier 2 Generic	010000	1	2	2	Tier 2 Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 Generic	2	Tier 2 Generic																						Tier 2 Generic	10.00	30.00								10.00			20.00								10.00			
H1099	006	0	1	01	01	H1099_006_0	6	4	4	3	Tier 4 Specialty	000010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H1108	006	0	1	04	01	H1108_006_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H1108	006	0	1	04	01	H1108_006_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1108	006	0	1	04	01	H1108_006_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1108	006	0	1	04	01	H1108_006_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H1109	001	0	1	01	01	H1109_001_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H1109	001	0	1	01	01	H1109_001_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H1109	001	0	1	01	01	H1109_001_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H1109	001	0	1	01	01	H1109_001_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H1109	001	0	1	01	01	H1109_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H1109	003	0	1	01	01	H1109_003_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H1109	003	0	1	01	01	H1109_003_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H1109	003	0	1	01	01	H1109_003_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H1109	003	0	1	01	01	H1109_003_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H1109	003	0	1	01	01	H1109_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H1109	003	0	1	01	01	H1109_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H1109	003	0	1	01	01	H1109_003_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H1109	003	0	1	01	01	H1109_003_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H1109	003	0	1	01	01	H1109_003_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																						2		
H1109	003	0	1	01	01	H1109_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H1110	001	0	1	04	01	H1110_001_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H1110	001	0	1	04	01	H1110_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00			
H1110	001	0	1	04	01	H1110_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H1110	001	0	1	04	01	H1110_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H1110	001	0	1	04	01	H1110_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H1110	003	0	1	04	01	H1110_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H1110	003	0	1	04	01	H1110_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H1110	003	0	1	04	01	H1110_003_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H1110	003	0	1	04	01	H1110_003_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H1110	003	0	1	04	01	H1110_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H1111	002	0	1	02	01	H1111_002_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H1111	002	0	1	02	01	H1111_002_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	4.00	12.00								4.00						8.00			12.00		4.00			
H1111	002	0	1	02	01	H1111_002_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1111	002	0	1	02	01	H1111_002_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1111	005	0	1	02	01	H1111_005_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1111	005	0	1	02	01	H1111_005_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H1111	005	0	1	02	01	H1111_005_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H1111	005	0	1	02	01	H1111_005_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1112	001	0	1	01	01	H1112_001_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1112	001	0	1	01	01	H1112_001_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	3	4	1	Tier 3	000100	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1112	001	0	1	01	01	H1112_001_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1112	005	0	1	01	01	H1112_005_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1112	005	0	1	01	01	H1112_005_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1112	005	0	1	01	01	H1112_005_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H1112	005	0	1	01	01	H1112_005_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00			
H1112	006	0	1	01	01	H1112_006_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00			
H1112	006	0	1	01	01	H1112_006_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
H1112	006	0	1	01	01	H1112_006_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1112	006	0	1	01	01	H1112_006_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1112	027	0	1	01	01	H1112_027_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1112	027	0	1	01	01	H1112_027_0	5	3	4	1	Tier 3	000100	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
H1112	027	0	1	01	01	H1112_027_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1112	027	0	1	01	01	H1112_027_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H1170	002	0	1	01	01	H1170_002_0	6	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1170	002	0	1	01	01	H1170_002_0	6	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H1170	002	0	1	01	01	H1170_002_0	6	1	4	3	Generic	010000	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Generic	2	Generic																						Generic				8.00	24.00		24.00	72.00		24.00		8.00	16.00								24.00	1	1	
H1170	002	0	1	01	01	H1170_002_0	6	3	4	1	Specialty	000010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
H1170	002	0	1	01	01	H1170_002_0	6	2	4	1	Brand	000010	1	2	1	Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Brand	2	Brand																						Brand				40.00	120.00		60.00	180.00		60.00		40.00	80.00								60.00			
H1170	002	0	1	01	01	H1170_002_0	6	1	4	1	Generic	010000	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Generic	2	Generic																						Generic				8.00	24.00		24.00	72.00		24.00		8.00	16.00								24.00			
H1170	008	0	1	01	01	H1170_008_0	7	1	3	1	Generic	010000		2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Generic	2	Generic																						Generic				12.00	36.00		24.00	72.00		24.00		12.00	24.00								24.00			
H1170	008	0	1	01	01	H1170_008_0	7	2	3	1	Brand	000010		2	1	Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Brand	2	Brand																						Brand				39.00	117.00		59.00	177.00		59.00		39.00	78.00								59.00			
H1170	008	0	1	01	01	H1170_008_0	7	3	3	1	Specialty	000010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
H1170	009	0	1	01	01	H1170_009_0	6	1	4	3	Generic	010000	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Generic	2	Generic																						Generic				10.00	30.00		24.00	72.00		24.00		10.00	20.00								24.00	1	1	
H1170	009	0	1	01	01	H1170_009_0	6	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H1170	009	0	1	01	01	H1170_009_0	6	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1170	009	0	1	01	01	H1170_009_0	6	3	4	1	Specialty	000010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
H1170	009	0	1	01	01	H1170_009_0	6	2	4	1	Brand	000010	1	2	1	Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Brand	2	Brand																						Brand				40.00	120.00		60.00	180.00		60.00		40.00	80.00								60.00			
H1170	009	0	1	01	01	H1170_009_0	6	1	4	1	Generic	010000	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	1	Generic	2	Generic																						Generic				10.00	30.00		24.00	72.00		24.00		10.00	20.00								24.00			
H1216	001	0	1	02	01	H1216_001_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1216	001	0	1	02	01	H1216_001_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1216	001	0	1	02	01	H1216_001_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1216	003	0	1	01	01	H1216_003_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1216	003	0	1	01	01	H1216_003_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00			
H1216	003	0	1	01	01	H1216_003_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1216	003	0	1	01	01	H1216_003_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00			
H1230	001	0	1	01	01	H1230_001_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H1230	001	0	1	01	01	H1230_001_0	7	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H1230	001	0	1	01	01	H1230_001_0	7	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	1	Brand	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H1230	001	0	1	01	01	H1230_001_0	7	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1230	001	0	1	01	01	H1230_001_0	7	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H1230	001	0	1	01	01	H1230_001_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H1230	003	0	1	01	01	H1230_003_0	7	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H1230	003	0	1	01	01	H1230_003_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H1230	003	0	1	01	01	H1230_003_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H1230	003	0	1	01	01	H1230_003_0	7	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1230	003	0	1	01	01	H1230_003_0	7	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H1230	003	0	1	01	01	H1230_003_0	7	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	1	Brand	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H1251	003	0	1	18	06	H1251_003_0	4	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H1251	003	0	1	18	06	H1251_003_0	4	3	2	1	Other Brand	100000		2	1	Other Brand	111000000010010000000	30	90								30			90								34	1	Other Brand	2	Other Brand																						Other Brand	65.00	195.00								65.00			130.00								65.00			
H1251	003	0	1	18	06	H1251_003_0	4	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	3.00	9.00								3.00			0.00								3.00			
H1251	003	0	1	18	06	H1251_003_0	4	4	2	1	Injectables	100000		2	2	Injectables	111000000010000000000	30	90								30											34	1	Injectables	1	Injectables	25	25								25											25	Injectables																								
H1251	003	0	1	18	06	H1251_003_0	4	5	2	1	Specialty Drugs	100000		1	2	Specialty Drugs	111000000010000000000	30	90								30											34	1	Specialty Drugs	1	Specialty Drugs	25	25								25											25	Specialty Drugs																								
H1251	004	0	1	18	06	H1251_004_0	4	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	3.00	9.00								3.00			0.00								3.00			
H1251	004	0	1	18	06	H1251_004_0	4	5	2	1	Specialty Drugs	100000		1	2	Specialty Drugs	111000000010000000000	30	90								30											34	1	Specialty Drugs	1	Specialty Drugs	25	25								25											25	Specialty Drugs																								
H1251	004	0	1	18	06	H1251_004_0	4	3	2	1	Other Brand	100000		2	1	Other Brand	111000000010010000000	30	90								30			90								34	1	Other Brand	2	Other Brand																						Other Brand	65.00	195.00								65.00			130.00								65.00			
H1251	004	0	1	18	06	H1251_004_0	4	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00			
H1251	004	0	1	18	06	H1251_004_0	4	4	2	1	Injectables	100000		2	2	Injectables	111000000010000000000	30	90								30											34	1	Injectables	1	Injectables	25	25								25											25	Injectables																								
H1251	011	0	1	18	06	H1251_011_0	5	5	2	1	Specialty Drugs	100000		1	2	Specialty Drugs	111000000010000000000	30	90								30											34	1	Specialty Drugs	1	Specialty Drugs	25	25								25											25	Specialty Drugs																								
H1251	011	0	1	18	06	H1251_011_0	5	3	2	1	Other Brand	100000		2	1	Other Brand	111000000010010000000	30	90								30			90								34	1	Other Brand	2	Other Brand																						Other Brand	65.00	195.00								65.00			130.00								65.00			
H1251	011	0	1	18	06	H1251_011_0	5	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	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	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	3.00	9.00								3.00			0.00								3.00			
H1251	011	0	1	18	06	H1251_011_0	5	4	2	1	Injectables	100000		2	2	Injectables	111000000010000000000	30	90								30											34	1	Injectables	1	Injectables	25	25								25											25	Injectables																								
H1264	004	0	1	02	01	H1264_004_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00			
H1264	004	0	1	02	01	H1264_004_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1264	004	0	1	02	01	H1264_004_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H1264	004	0	1	02	01	H1264_004_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1264	007	0	1	01	01	H1264_007_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
H1264	007	0	1	01	01	H1264_007_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00			
H1264	007	0	1	01	01	H1264_007_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H1264	007	0	1	01	01	H1264_007_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1264	008	0	1	02	01	H1264_008_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1264	008	0	1	02	01	H1264_008_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H1264	008	0	1	02	01	H1264_008_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00			
H1264	008	0	1	02	01	H1264_008_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1264	014	0	1	02	01	H1264_014_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1264	014	0	1	02	01	H1264_014_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00			
H1264	014	0	1	02	01	H1264_014_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H1264	014	0	1	02	01	H1264_014_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1286	002	0	1	02	01	H1286_002_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H1286	002	0	1	02	01	H1286_002_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H1286	002	0	1	02	01	H1286_002_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1286	002	0	1	02	01	H1286_002_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1286	004	0	1	02	01	H1286_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1286	004	0	1	02	01	H1286_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1286	004	0	1	02	01	H1286_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H1286	004	0	1	02	01	H1286_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H1286	008	0	1	02	01	H1286_008_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H1286	008	0	1	02	01	H1286_008_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	78.00	234.00								78.00						224.00			234.00		78.00			
H1286	008	0	1	02	01	H1286_008_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1286	008	0	1	02	01	H1286_008_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1302	001	0	1	04	01	H1302_001_0	5	3	4	1	Tier 3 - Non Preferred Brand	100000	1	2	1	Tier 3 - Non Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Tier 3 - Non Preferred Brand	2	Tier 3 - Non Preferred Brand																						Tier 3 - Non Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00			
H1302	001	0	1	04	01	H1302_001_0	5	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00			
H1302	001	0	1	04	01	H1302_001_0	5	4	4	1	Tier 4 - Injectable Drugs	101101	1	2	2	Tier 4 - Injectable Drugs	111000000010110000000	30	90								30		30	90								31	1	Tier 4 - Injectable Drugs	1	Tier 4 - Injectable Drugs	25	25								25		25	25								25	Tier 4 - Injectable Drugs																								
H1302	001	0	1	04	01	H1302_001_0	5	5	4	1	Tier 5 - Specialty Drugs	101101	1	1	2	Tier 5 - Specialty Drugs	111000000010110000000	30	90								30		30	90								31	1	Tier 5 - Specialty Drugs	1	Tier 5 - Specialty Drugs	25	25								25		25	25								25	Tier 5 - Specialty Drugs																								
H1302	001	0	1	04	01	H1302_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00		6.00	18.00								6.00			
H1303	001	0	1	04	01	H1303_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H1303	001	0	1	04	01	H1303_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1303	001	0	1	04	01	H1303_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H1303	001	0	1	04	01	H1303_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H1303	006	0	1	04	01	H1303_006_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H1303	006	0	1	04	01	H1303_006_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1303	006	0	1	04	01	H1303_006_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H1303	006	0	1	04	01	H1303_006_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1304	002	0	1	04	01	H1304_002_0	4	4	3	1	Miscellaneous Injectables	110001		2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	27									27		27									27	Miscellaneous Injectables																								
H1304	002	0	1	04	01	H1304_002_0	4	5	3	1	Specialty	110001		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	27									27		27									27	Specialty																								
H1304	002	0	1	04	01	H1304_002_0	4	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H1304	002	0	1	04	01	H1304_002_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H1304	002	0	1	04	01	H1304_002_0	4	1	3	1	Generic	001000		2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H1304	004	0	1	04	01	H1304_004_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1304	004	0	1	04	01	H1304_004_0	5	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
H1304	004	0	1	04	01	H1304_004_0	5	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
H1304	004	0	1	04	01	H1304_004_0	5	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H1304	004	0	1	04	01	H1304_004_0	5	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1304	004	0	1	04	01	H1304_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H1304	004	0	1	04	01	H1304_004_0	5	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
H1304	004	0	1	04	01	H1304_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1304	004	0	1	04	01	H1304_004_0	5	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
H1304	004	0	1	04	01	H1304_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H1350	001	0	1	01	01	H1350_001_0	4	5	4	3	Tier 5 - Specialty Drugs	001111	1	1	2	Tier 5 - Specialty Drugs																								Tier 5 - Specialty Drugs		Tier 5 - Specialty Drugs																						Tier 5 - Specialty Drugs																						2		
H1350	001	0	1	01	01	H1350_001_0	4	4	4	3	Tier 4 - Injectable Drugs	001111	1	2	2	Tier 4 - Injectable Drugs																								Tier 4 - Injectable Drugs		Tier 4 - Injectable Drugs																						Tier 4 - Injectable Drugs																						2		
H1350	001	0	1	01	01	H1350_001_0	4	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand																								Tier 3 - Non-Preferred Brand		Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																						2		
H1350	001	0	1	01	01	H1350_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																						2		
H1350	001	0	1	01	01	H1350_001_0	4	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00		6.00	18.00								6.00	1	1	
H1350	001	0	1	01	01	H1350_001_0	4	5	4	1	Tier 5 - Specialty Drugs	001111	1	1	2	Tier 5 - Specialty Drugs	111000000010110000000	30	90								30		30	90								31	1	Tier 5 - Specialty Drugs	1	Tier 5 - Specialty Drugs	25	25								25		25	25								25	Tier 5 - Specialty Drugs																								
H1350	001	0	1	01	01	H1350_001_0	4	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Tier 3 - Non-Preferred Brand	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	4	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Tier 2 - Preferred Brand	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	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00		6.00	18.00								6.00			
H1350	001	0	1	01	01	H1350_001_0	4	4	4	1	Tier 4 - Injectable Drugs	001111	1	2	2	Tier 4 - Injectable Drugs	111000000010110000000	30	90								30		30	90								31	1	Tier 4 - Injectable Drugs	1	Tier 4 - Injectable Drugs	25	25								25		25	25								25	Tier 4 - Injectable Drugs																								
H1350	009	0	1	01	01	H1350_009_0	4	1	4	3	Tier 1 - Preferred Generics	001000	1	2	2	Tier 1 - Preferred Generics																								Tier 1 - Preferred Generics		Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics																						2		
H1350	009	0	1	01	01	H1350_009_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																						2		
H1350	009	0	1	01	01	H1350_009_0	4	3	4	3	Tier 3 - Non-Preferred Brand	000001	1	2	1	Tier 3 - Non-Preferred Brand																								Tier 3 - Non-Preferred Brand		Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																						2		
H1350	009	0	1	01	01	H1350_009_0	4	6	4	3	Tier 6 - Covered Drugs $0 Copay	101101	2	2	2	Tier 6 - Covered Drugs $0 Copay	111000000010110000000	30	90								30		30	90								31	1	Tier 6 - Covered Drugs $0 Copay	2	Tier 6 - Covered Drugs $0 Copay																						Tier 6 - Covered Drugs $0 Copay	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H1350	009	0	1	01	01	H1350_009_0	4	5	4	3	Tier 5 - Specialty	101101	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H1350	009	0	1	01	01	H1350_009_0	4	4	4	3	Tier 4 - Injectable	001001	1	2	2	Tier 4 - Injectable																								Tier 4 - Injectable		Tier 4 - Injectable																						Tier 4 - Injectable																						2		
H1355	001	0	1	04	01	H1355_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H1355	001	0	1	04	01	H1355_001_0	4	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H1355	001	0	1	04	01	H1355_001_0	4	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	4	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H1365	001	0	1	04	01	H1365_001_0	6	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1365	001	0	1	04	01	H1365_001_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1365	001	0	1	04	01	H1365_001_0	6	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010111000000	30	90								30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00	1	1	
H1365	001	0	1	04	01	H1365_001_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010111000000	30	90								30		30	90	60							31	1	Tier 4	1	Tier 4	25	25								25		25	25	25							25	Tier 4																								
H1365	001	0	1	04	01	H1365_001_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010111000000	30	90								30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	55.00	165.00								55.00		55.00	137.50	110.00							55.00			
H1365	001	0	1	04	01	H1365_001_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010111000000	30	90								30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00		35.00	87.50	70.00							35.00			
H1365	001	0	1	04	01	H1365_001_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010111000000	30	90								30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00			
H1365	001	0	1	04	01	H1365_001_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1406	013	0	1	01	01	H1406_013_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1406	013	0	1	01	01	H1406_013_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1406	013	0	1	01	01	H1406_013_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1406	013	0	1	01	01	H1406_013_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1406	013	0	1	01	01	H1406_013_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1406	013	0	1	01	01	H1406_013_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1406	013	0	1	01	01	H1406_013_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1406	022	0	1	01	01	H1406_022_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1406	022	0	1	01	01	H1406_022_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1406	022	0	1	01	01	H1406_022_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1406	022	0	1	01	01	H1406_022_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1406	022	0	1	01	01	H1406_022_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1406	022	0	1	01	01	H1406_022_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1406	022	0	1	01	01	H1406_022_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1406	022	0	1	01	01	H1406_022_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1415	015	0	1	01	01	H1415_015_0	9	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1415	015	0	1	01	01	H1415_015_0	9	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50	1	2	01000000
H1415	015	0	1	01	01	H1415_015_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50			
H1415	015	0	1	01	01	H1415_015_0	9	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50			
H1415	015	0	1	01	01	H1415_015_0	9	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1415	015	0	1	01	01	H1415_015_0	9	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																								
H1415	015	0	1	01	01	H1415_015_0	9	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50	1	1	
H1415	015	0	1	01	01	H1415_015_0	9	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H1415	015	0	1	01	01	H1415_015_0	9	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1415	015	0	1	01	01	H1415_015_0	9	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H1415	017	0	1	02	01	H1415_017_0	8	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1415	017	0	1	02	01	H1415_017_0	8	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1415	017	0	1	02	01	H1415_017_0	8	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1415	017	0	1	02	01	H1415_017_0	8	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00	1	1	
H1415	017	0	1	02	01	H1415_017_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H1415	017	0	1	02	01	H1415_017_0	8	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	8	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H1415	017	0	1	02	01	H1415_017_0	8	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H1415	017	0	1	02	01	H1415_017_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H1415	017	0	1	02	01	H1415_017_0	8	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H1415	021	0	1	02	01	H1415_021_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H1415	021	0	1	02	01	H1415_021_0	9	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H1415	021	0	1	02	01	H1415_021_0	9	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H1415	021	0	1	02	01	H1415_021_0	9	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H1415	021	0	1	02	01	H1415_021_0	9	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1415	021	0	1	02	01	H1415_021_0	9	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H1415	021	0	1	02	01	H1415_021_0	9	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	1	
H1415	021	0	1	02	01	H1415_021_0	9	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1415	021	0	1	02	01	H1415_021_0	9	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1415	021	0	1	02	01	H1415_021_0	9	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H1415	023	0	1	02	01	H1415_023_0	10	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H1415	023	0	1	02	01	H1415_023_0	10	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H1415	023	0	1	02	01	H1415_023_0	10	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H1415	023	0	1	02	01	H1415_023_0	10	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H1415	023	0	1	02	01	H1415_023_0	10	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H1415	023	0	1	02	01	H1415_023_0	10	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H1415	023	0	1	02	01	H1415_023_0	10	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	1	
H1415	023	0	1	02	01	H1415_023_0	10	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1415	023	0	1	02	01	H1415_023_0	10	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1415	023	0	1	02	01	H1415_023_0	10	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1416	007	0	1	01	01	H1416_007_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1416	007	0	1	01	01	H1416_007_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	77.00	231.00								77.00			231.00								77.00			
H1416	007	0	1	01	01	H1416_007_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1416	009	0	1	02	01	H1416_009_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1416	009	0	1	02	01	H1416_009_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1416	009	0	1	02	01	H1416_009_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1416	009	0	1	02	01	H1416_009_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H1416	018	0	1	02	01	H1416_018_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1416	018	0	1	02	01	H1416_018_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1416	018	0	1	02	01	H1416_018_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00								29.00			87.00								29.00			
H1416	018	0	1	02	01	H1416_018_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1416	019	0	1	02	01	H1416_019_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1416	019	0	1	02	01	H1416_019_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1416	019	0	1	02	01	H1416_019_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1416	020	0	1	02	01	H1416_020_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1416	020	0	1	02	01	H1416_020_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1416	020	0	1	02	01	H1416_020_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1417	002	0	1	04	01	H1417_002_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00		39.00	117.00								39.00			
H1417	002	0	1	04	01	H1417_002_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00								88.00		88.00	264.00								88.00			
H1417	002	0	1	04	01	H1417_002_0	6	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H1417	004	0	1	04	01	H1417_004_0	12	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H1417	004	0	1	04	01	H1417_004_0	12	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00								88.00		88.00	264.00								88.00			
H1417	004	0	1	04	01	H1417_004_0	12	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00		39.00	117.00								39.00			
H1417	004	0	1	04	01	H1417_004_0	12	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	11	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H1417	005	0	1	04	01	H1417_005_0	11	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	11	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1417	005	0	1	04	01	H1417_005_0	11	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1417	005	0	1	04	01	H1417_005_0	11	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1417	005	0	1	04	01	H1417_005_0	11	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00	1	1	
H1417	005	0	1	04	01	H1417_005_0	11	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00								88.00		88.00	264.00								88.00			
H1417	005	0	1	04	01	H1417_005_0	11	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00		39.00	117.00								39.00			
H1417	006	0	1	04	01	H1417_006_0	12	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00								88.00		88.00	264.00								88.00			
H1417	006	0	1	04	01	H1417_006_0	12	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00		39.00	117.00								39.00			
H1417	006	0	1	04	01	H1417_006_0	12	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	12	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1417	006	0	1	04	01	H1417_006_0	12	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H1417	006	0	1	04	01	H1417_006_0	12	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1417	006	0	1	04	01	H1417_006_0	12	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1417	006	0	1	04	01	H1417_006_0	12	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00	1	1	
H1418	002	0	1	04	01	H1418_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1418	002	0	1	04	01	H1418_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1418	002	0	1	04	01	H1418_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1418	002	0	1	04	01	H1418_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	002	0	1	04	01	H1418_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	002	0	1	04	01	H1418_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1418	002	0	1	04	01	H1418_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1418	002	0	1	04	01	H1418_002_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1418	007	0	1	04	01	H1418_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	007	0	1	04	01	H1418_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H1418	007	0	1	04	01	H1418_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1418	007	0	1	04	01	H1418_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H1418	007	0	1	04	01	H1418_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1418	007	0	1	04	01	H1418_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1418	007	0	1	04	01	H1418_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H1418	007	0	1	04	01	H1418_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	008	0	1	04	01	H1418_008_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1418	008	0	1	04	01	H1418_008_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1418	008	0	1	04	01	H1418_008_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1418	008	0	1	04	01	H1418_008_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	008	0	1	04	01	H1418_008_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1418	008	0	1	04	01	H1418_008_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1418	008	0	1	04	01	H1418_008_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1418	008	0	1	04	01	H1418_008_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	010	0	1	04	01	H1418_010_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H1418	010	0	1	04	01	H1418_010_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	010	0	1	04	01	H1418_010_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1418	010	0	1	04	01	H1418_010_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1418	010	0	1	04	01	H1418_010_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	010	0	1	04	01	H1418_010_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1418	010	0	1	04	01	H1418_010_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1418	010	0	1	04	01	H1418_010_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1418	011	0	1	04	01	H1418_011_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H1418	011	0	1	04	01	H1418_011_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1418	011	0	1	04	01	H1418_011_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1418	011	0	1	04	01	H1418_011_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1418	011	0	1	04	01	H1418_011_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	011	0	1	04	01	H1418_011_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1418	011	0	1	04	01	H1418_011_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1418	011	0	1	04	01	H1418_011_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	012	0	1	04	01	H1418_012_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	012	0	1	04	01	H1418_012_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H1418	012	0	1	04	01	H1418_012_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1418	012	0	1	04	01	H1418_012_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1418	012	0	1	04	01	H1418_012_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	012	0	1	04	01	H1418_012_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1418	012	0	1	04	01	H1418_012_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1418	012	0	1	04	01	H1418_012_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1418	013	0	1	04	01	H1418_013_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1418	013	0	1	04	01	H1418_013_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1418	013	0	1	04	01	H1418_013_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1418	013	0	1	04	01	H1418_013_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	013	0	1	04	01	H1418_013_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1418	013	0	1	04	01	H1418_013_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1418	013	0	1	04	01	H1418_013_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1418	013	0	1	04	01	H1418_013_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	014	0	1	04	01	H1418_014_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1418	014	0	1	04	01	H1418_014_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1418	014	0	1	04	01	H1418_014_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1418	014	0	1	04	01	H1418_014_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H1418	014	0	1	04	01	H1418_014_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1418	014	0	1	04	01	H1418_014_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1418	014	0	1	04	01	H1418_014_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1418	014	0	1	04	01	H1418_014_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1419	001	0	1	01	01	H1419_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H1419	001	0	1	01	01	H1419_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	33.00	99.00									33.00					66.00			99.00		33.00			
H1419	001	0	1	01	01	H1419_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H1419	001	0	1	01	01	H1419_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00			
H1419	001	0	1	01	01	H1419_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H1419	003	0	1	01	01	H1419_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	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	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H1419	003	0	1	01	01	H1419_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H1419	003	0	1	01	01	H1419_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H1419	003	0	1	01	01	H1419_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H1463	003	0	1	01	01	H1463_003_0	3	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00								88.00		88.00	264.00								88.00			
H1463	003	0	1	01	01	H1463_003_0	3	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00		39.00	117.00								39.00			
H1463	003	0	1	01	01	H1463_003_0	3	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	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	3	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H1463	005	0	1	01	01	H1463_005_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00		39.00	117.00								39.00			
H1463	005	0	1	01	01	H1463_005_0	2	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H1463	005	0	1	01	01	H1463_005_0	2	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H1463	005	0	1	01	01	H1463_005_0	2	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H1463	005	0	1	01	01	H1463_005_0	2	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00	1	1	
H1463	005	0	1	01	01	H1463_005_0	2	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H1463	005	0	1	01	01	H1463_005_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00								88.00		88.00	264.00								88.00			
H1463	005	0	1	01	01	H1463_005_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00		6.00	18.00								6.00			
H1468	007	0	1	01	01	H1468_007_0	6	2	4	3	Non-Preferred Generic and Preferred Brand	000111	1	2	2	Non-Preferred Generic and Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic and Preferred Brand	2	Non-Preferred Generic and Preferred Brand																						Non-Preferred Generic and Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1468	007	0	1	01	01	H1468_007_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1468	007	0	1	01	01	H1468_007_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1468	007	0	1	01	01	H1468_007_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1468	007	0	1	01	01	H1468_007_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1468	007	0	1	01	01	H1468_007_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1468	007	0	1	01	01	H1468_007_0	6	2	4	1	Non-Preferred Generic and Preferred Brand	000111	1	2	2	Non-Preferred Generic and Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic and Preferred Brand	2	Non-Preferred Generic and Preferred Brand																						Non-Preferred Generic and Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1468	007	0	1	01	01	H1468_007_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H1509	001	0	1	04	01	H1509_001_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1509	001	0	1	04	01	H1509_001_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H1509	001	0	1	04	01	H1509_001_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1509	001	0	1	04	01	H1509_001_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1509	005	0	1	04	01	H1509_005_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H1509	005	0	1	04	01	H1509_005_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H1509	005	0	1	04	01	H1509_005_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1509	005	0	1	04	01	H1509_005_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1509	007	0	1	04	01	H1509_007_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H1509	007	0	1	04	01	H1509_007_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H1509	007	0	1	04	01	H1509_007_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1509	007	0	1	04	01	H1509_007_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1509	009	0	1	04	01	H1509_009_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00			
H1509	009	0	1	04	01	H1509_009_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1509	009	0	1	04	01	H1509_009_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1509	009	0	1	04	01	H1509_009_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1510	001	0	1	04	01	H1510_001_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1510	001	0	1	04	01	H1510_001_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1510	001	0	1	04	01	H1510_001_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1510	001	0	1	04	01	H1510_001_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H1510	001	0	1	04	01	H1510_001_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1510	001	0	1	04	01	H1510_001_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1510	001	0	1	04	01	H1510_001_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H1510	004	0	1	04	01	H1510_004_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1510	004	0	1	04	01	H1510_004_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1510	004	0	1	04	01	H1510_004_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1510	004	0	1	04	01	H1510_004_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1510	004	0	1	04	01	H1510_004_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1510	004	0	1	04	01	H1510_004_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1510	004	0	1	04	01	H1510_004_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1510	005	0	1	04	01	H1510_005_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1510	005	0	1	04	01	H1510_005_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1510	005	0	1	04	01	H1510_005_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1510	005	0	1	04	01	H1510_005_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1510	005	0	1	04	01	H1510_005_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1510	005	0	1	04	01	H1510_005_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1510	005	0	1	04	01	H1510_005_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1517	001	0	1	04	01	H1517_001_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H1517	001	0	1	04	01	H1517_001_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H1517	001	0	1	04	01	H1517_001_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1517	001	0	1	04	01	H1517_001_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1517	001	0	1	04	01	H1517_001_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1517	001	0	1	04	01	H1517_001_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H1517	001	0	1	04	01	H1517_001_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1517	001	0	1	04	01	H1517_001_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1517	001	0	1	04	01	H1517_001_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1517	001	0	1	04	01	H1517_001_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1517	003	0	1	04	01	H1517_003_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H1517	003	0	1	04	01	H1517_003_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1517	003	0	1	04	01	H1517_003_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1517	003	0	1	04	01	H1517_003_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1517	003	0	1	04	01	H1517_003_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1517	003	0	1	04	01	H1517_003_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H1517	003	0	1	04	01	H1517_003_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1517	003	0	1	04	01	H1517_003_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1517	003	0	1	04	01	H1517_003_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1517	003	0	1	04	01	H1517_003_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H1595	001	0	1	04	01	H1595_001_0	7	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	74.00								37.00		37.00	74.00								37.00			
H1595	001	0	1	04	01	H1595_001_0	7	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	148.00								74.00		74.00	148.00								74.00			
H1595	001	0	1	04	01	H1595_001_0	7	4	3	1	Specialty	110100		1	2	Specialty	110000000010000000000	34									34											34		Specialty	4	Specialty	25									25											25	Specialty	125.00									125.00											125.00			
H1595	001	0	1	04	01	H1595_001_0	7	1	3	1	Generic	010000		2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	8.00	16.00								8.00		8.00	16.00								8.00			
H1595	002	0	1	04	01	H1595_002_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	6.00	12.00								6.00		6.00	12.00								6.00			
H1595	002	0	1	04	01	H1595_002_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1595	002	0	1	04	01	H1595_002_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1595	002	0	1	04	01	H1595_002_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	70.00								35.00		35.00	70.00								35.00			
H1595	002	0	1	04	01	H1595_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	140.00								70.00		70.00	140.00								70.00			
H1595	002	0	1	04	01	H1595_002_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	6.00	12.00								6.00		6.00	12.00								6.00	1	1	
H1595	002	0	1	04	01	H1595_002_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	110000000010000000000	34									34											34		Specialty	4	Specialty	25									25											25	Specialty	125.00									125.00											125.00			
H1595	002	0	1	04	01	H1595_002_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1607	001	0	1	04	01	H1607_001_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H1607	001	0	1	04	01	H1607_001_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H1607	001	0	1	04	01	H1607_001_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1607	001	0	1	04	01	H1607_001_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1607	001	0	1	04	01	H1607_001_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1607	001	0	1	04	01	H1607_001_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H1607	001	0	1	04	01	H1607_001_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1607	001	0	1	04	01	H1607_001_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1607	001	0	1	04	01	H1607_001_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1607	001	0	1	04	01	H1607_001_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1607	004	0	1	04	01	H1607_004_0	8	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H1607	004	0	1	04	01	H1607_004_0	8	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H1607	004	0	1	04	01	H1607_004_0	8	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1607	004	0	1	04	01	H1607_004_0	8	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1607	004	0	1	04	01	H1607_004_0	8	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1607	004	0	1	04	01	H1607_004_0	8	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H1607	004	0	1	04	01	H1607_004_0	8	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1607	004	0	1	04	01	H1607_004_0	8	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1607	004	0	1	04	01	H1607_004_0	8	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1607	004	0	1	04	01	H1607_004_0	8	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1608	001	0	1	04	01	H1608_001_0	8	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H1608	001	0	1	04	01	H1608_001_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H1608	001	0	1	04	01	H1608_001_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H1608	001	0	1	04	01	H1608_001_0	8	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H1608	003	0	1	04	01	H1608_003_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H1608	003	0	1	04	01	H1608_003_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H1608	003	0	1	04	01	H1608_003_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H1608	003	0	1	04	01	H1608_003_0	7	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H1609	001	0	1	01	01	H1609_001_0	8	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	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	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H1609	001	0	1	01	01	H1609_001_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H1609	001	0	1	01	01	H1609_001_0	8	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H1609	007	0	1	01	01	H1609_007_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H1609	007	0	1	01	01	H1609_007_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H1609	007	0	1	01	01	H1609_007_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H1609	007	0	1	01	01	H1609_007_0	7	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H1643	001	0	1	09	04	H1643_001_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H1643	001	0	1	09	04	H1643_001_0	9	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H1643	001	0	1	09	04	H1643_001_0	9	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H1643	001	0	1	09	04	H1643_001_0	9	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H1657	002	0	1	02	01	H1657_002_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1657	002	0	1	02	01	H1657_002_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1657	002	0	1	02	01	H1657_002_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1657	004	0	1	01	01	H1657_004_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1657	004	0	1	01	01	H1657_004_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1657	004	0	1	01	01	H1657_004_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00			
H1657	008	0	1	02	01	H1657_008_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1657	008	0	1	02	01	H1657_008_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00								40.00			120.00								40.00			
H1657	008	0	1	02	01	H1657_008_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1657	008	0	1	02	01	H1657_008_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	20.00	60.00								20.00			60.00								20.00			
H1681	001	0	1	04	01	H1681_001_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	001	0	1	04	01	H1681_001_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1681	001	0	1	04	01	H1681_001_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	001	0	1	04	01	H1681_001_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1681	001	0	1	04	01	H1681_001_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1681	001	0	1	04	01	H1681_001_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	001	0	1	04	01	H1681_001_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	002	0	1	04	01	H1681_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	002	0	1	04	01	H1681_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1681	002	0	1	04	01	H1681_002_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1681	002	0	1	04	01	H1681_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	002	0	1	04	01	H1681_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	002	0	1	04	01	H1681_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	002	0	1	04	01	H1681_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1681	002	0	1	04	01	H1681_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1681	003	0	1	04	01	H1681_003_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1681	003	0	1	04	01	H1681_003_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	003	0	1	04	01	H1681_003_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	003	0	1	04	01	H1681_003_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1681	003	0	1	04	01	H1681_003_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1681	003	0	1	04	01	H1681_003_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	003	0	1	04	01	H1681_003_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	004	0	1	04	01	H1681_004_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	004	0	1	04	01	H1681_004_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	004	0	1	04	01	H1681_004_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1681	004	0	1	04	01	H1681_004_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1681	004	0	1	04	01	H1681_004_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	004	0	1	04	01	H1681_004_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	004	0	1	04	01	H1681_004_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1681	004	0	1	04	01	H1681_004_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1681	005	0	1	04	01	H1681_005_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1681	005	0	1	04	01	H1681_005_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1681	005	0	1	04	01	H1681_005_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	005	0	1	04	01	H1681_005_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	005	0	1	04	01	H1681_005_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1681	005	0	1	04	01	H1681_005_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1681	005	0	1	04	01	H1681_005_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	005	0	1	04	01	H1681_005_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	006	0	1	04	01	H1681_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1681	006	0	1	04	01	H1681_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	006	0	1	04	01	H1681_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1681	006	0	1	04	01	H1681_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1681	006	0	1	04	01	H1681_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	006	0	1	04	01	H1681_006_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	006	0	1	04	01	H1681_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1681	006	0	1	04	01	H1681_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	007	0	1	04	01	H1681_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1681	007	0	1	04	01	H1681_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1681	007	0	1	04	01	H1681_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1681	007	0	1	04	01	H1681_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1681	007	0	1	04	01	H1681_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1681	007	0	1	04	01	H1681_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1681	007	0	1	04	01	H1681_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1681	007	0	1	04	01	H1681_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1689	013	0	1	09	04	H1689_013_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1689	013	0	1	09	04	H1689_013_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1689	013	0	1	09	04	H1689_013_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1689	013	0	1	09	04	H1689_013_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1689	013	0	1	09	04	H1689_013_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H1689	013	0	1	09	04	H1689_013_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1689	013	0	1	09	04	H1689_013_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1689	013	0	1	09	04	H1689_013_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1689	013	0	1	09	04	H1689_013_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H1689	013	0	1	09	04	H1689_013_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H1716	001	0	1	04	01	H1716_001_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1716	001	0	1	04	01	H1716_001_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1716	001	0	1	04	01	H1716_001_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1716	001	0	1	04	01	H1716_001_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1716	001	0	1	04	01	H1716_001_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1716	001	0	1	04	01	H1716_001_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1716	001	0	1	04	01	H1716_001_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1716	001	0	1	04	01	H1716_001_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1716	002	0	1	04	01	H1716_002_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1716	002	0	1	04	01	H1716_002_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1716	002	0	1	04	01	H1716_002_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H1716	002	0	1	04	01	H1716_002_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1716	002	0	1	04	01	H1716_002_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1716	002	0	1	04	01	H1716_002_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1716	002	0	1	04	01	H1716_002_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1716	002	0	1	04	01	H1716_002_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1716	004	0	1	04	01	H1716_004_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1716	004	0	1	04	01	H1716_004_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1716	004	0	1	04	01	H1716_004_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H1716	004	0	1	04	01	H1716_004_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1716	004	0	1	04	01	H1716_004_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1716	004	0	1	04	01	H1716_004_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1716	004	0	1	04	01	H1716_004_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H1716	004	0	1	04	01	H1716_004_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1716	006	0	1	04	01	H1716_006_0	11	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1716	006	0	1	04	01	H1716_006_0	11	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1716	006	0	1	04	01	H1716_006_0	11	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1716	006	0	1	04	01	H1716_006_0	11	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1716	006	0	1	04	01	H1716_006_0	11	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1716	006	0	1	04	01	H1716_006_0	11	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1716	006	0	1	04	01	H1716_006_0	11	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1716	006	0	1	04	01	H1716_006_0	11	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1717	001	0	1	04	01	H1717_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1717	001	0	1	04	01	H1717_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1717	001	0	1	04	01	H1717_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H1717	001	0	1	04	01	H1717_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1717	010	0	1	04	01	H1717_010_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1717	010	0	1	04	01	H1717_010_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H1717	010	0	1	04	01	H1717_010_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H1717	010	0	1	04	01	H1717_010_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1804	128	0	1	09	04	H1804_128_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1804	128	0	1	09	04	H1804_128_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1804	128	0	1	09	04	H1804_128_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1804	128	0	1	09	04	H1804_128_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1804	128	0	1	09	04	H1804_128_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1804	128	0	1	09	04	H1804_128_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1804	128	0	1	09	04	H1804_128_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1804	128	0	1	09	04	H1804_128_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1806	001	0	1	04	01	H1806_001_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1806	001	0	1	04	01	H1806_001_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	100111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1806	001	0	1	04	01	H1806_001_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1806	001	0	1	04	01	H1806_001_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1806	001	0	1	04	01	H1806_001_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1806	001	0	1	04	01	H1806_001_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	100111	1	2	2	Non-Preferred Generic/ Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/ Preferred Brand	2	Non-Preferred Generic/ Preferred Brand																						Non-Preferred Generic/ Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1806	001	0	1	04	01	H1806_001_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1806	002	0	1	04	01	H1806_002_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1806	002	0	1	04	01	H1806_002_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1806	002	0	1	04	01	H1806_002_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1806	002	0	1	04	01	H1806_002_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1806	002	0	1	04	01	H1806_002_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1806	002	0	1	04	01	H1806_002_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1806	002	0	1	04	01	H1806_002_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1806	005	0	1	04	01	H1806_005_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H1806	005	0	1	04	01	H1806_005_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1806	005	0	1	04	01	H1806_005_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1806	005	0	1	04	01	H1806_005_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1806	005	0	1	04	01	H1806_005_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H1806	005	0	1	04	01	H1806_005_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1806	005	0	1	04	01	H1806_005_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1806	005	0	1	04	01	H1806_005_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1806	006	0	1	04	01	H1806_006_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H1806	006	0	1	04	01	H1806_006_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1806	006	0	1	04	01	H1806_006_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1806	006	0	1	04	01	H1806_006_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1806	006	0	1	04	01	H1806_006_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1806	006	0	1	04	01	H1806_006_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1806	006	0	1	04	01	H1806_006_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1806	006	0	1	04	01	H1806_006_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1837	001	0	1	01	01	H1837_001_0	6	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H1837	001	0	1	01	01	H1837_001_0	6	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	118.00									59.00	59.00	118.00								59.00			
H1837	001	0	1	01	01	H1837_001_0	6	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	001	0	1	01	01	H1837_001_0	6	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H1837	002	0	1	01	01	H1837_002_0	4	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	002	0	1	01	01	H1837_002_0	4	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	118.00									59.00	59.00	118.00								59.00			
H1837	002	0	1	01	01	H1837_002_0	4	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H1837	002	0	1	01	01	H1837_002_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H1837	003	0	1	01	01	H1837_003_0	7	4	4	3	Tier 4 specialty	100011	1	1	2	Tier 4 specialty																								Tier 4 specialty		Tier 4 specialty																						Tier 4 specialty																						2		
H1837	003	0	1	01	01	H1837_003_0	7	3	4	3	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand																								Tier 3 non-preferred brand		Tier 3 non-preferred brand																						Tier 3 non-preferred brand																						2		
H1837	003	0	1	01	01	H1837_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																						2		
H1837	003	0	1	01	01	H1837_003_0	7	1	4	3	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00	1	1	
H1837	003	0	1	01	01	H1837_003_0	7	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	003	0	1	01	01	H1837_003_0	7	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	50.00	100.00									50.00	50.00	100.00								50.00			
H1837	003	0	1	01	01	H1837_003_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	20.00	40.00									20.00	20.00	40.00								20.00			
H1837	003	0	1	01	01	H1837_003_0	7	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00			
H1837	005	0	1	01	01	H1837_005_0	6	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	118.00									59.00	59.00	118.00								59.00			
H1837	005	0	1	01	01	H1837_005_0	6	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	005	0	1	01	01	H1837_005_0	6	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H1837	005	0	1	01	01	H1837_005_0	6	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H1837	006	0	1	01	01	H1837_006_0	5	1	4	3	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00	1	1	
H1837	006	0	1	01	01	H1837_006_0	5	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00			
H1837	006	0	1	01	01	H1837_006_0	5	3	4	3	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand																								Tier 3 non-preferred brand		Tier 3 non-preferred brand																						Tier 3 non-preferred brand																						2		
H1837	006	0	1	01	01	H1837_006_0	5	4	4	3	Tier 4 specialty	100011	1	1	2	Tier 4 specialty																								Tier 4 specialty		Tier 4 specialty																						Tier 4 specialty																						2		
H1837	006	0	1	01	01	H1837_006_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																						2		
H1837	006	0	1	01	01	H1837_006_0	5	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	20.00	40.00									20.00	20.00	40.00								20.00			
H1837	006	0	1	01	01	H1837_006_0	5	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	50.00	100.00									50.00	50.00	100.00								50.00			
H1837	006	0	1	01	01	H1837_006_0	5	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	007	0	1	01	01	H1837_007_0	6	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	118.00									59.00	59.00	118.00								59.00			
H1837	007	0	1	01	01	H1837_007_0	6	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								31	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H1837	007	0	1	01	01	H1837_007_0	6	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H1837	007	0	1	01	01	H1837_007_0	6	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	008	0	1	01	01	H1837_008_0	7	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								31	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H1837	008	0	1	01	01	H1837_008_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H1837	008	0	1	01	01	H1837_008_0	7	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	118.00									59.00	59.00	118.00								59.00			
H1837	008	0	1	01	01	H1837_008_0	7	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	009	0	1	01	01	H1837_009_0	6	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								31	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H1837	009	0	1	01	01	H1837_009_0	6	4	4	1	Tier 4 specialty	100011	1	1	2	Tier 4 specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 specialty	1	Tier 4 specialty	20	20									20	20	20								20	Tier 4 specialty																								
H1837	009	0	1	01	01	H1837_009_0	6	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H1837	009	0	1	01	01	H1837_009_0	6	3	4	1	Tier 3 non-preferred brand	100000	1	2	1	Tier 3 non-preferred brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 non-preferred brand	2	Tier 3 non-preferred brand																						Tier 3 non-preferred brand	59.00	118.00									59.00	59.00	118.00								59.00			
H1846	001	0	1	04	01	H1846_001_0	6	5	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H1846	001	0	1	04	01	H1846_001_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1846	001	0	1	04	01	H1846_001_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1846	001	0	1	04	01	H1846_001_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H1846	001	0	1	04	01	H1846_001_0	6	1	4	1	Value Generic	001000	1	2	2	Value Generic	111000000010110000000	30	90								30		30	90								31	1	Value Generic	2	Value Generic																						Value Generic	5.00	15.00								5.00		5.00	10.00								5.00			
H1846	001	0	1	04	01	H1846_001_0	6	5	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	1	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H1846	001	0	1	04	01	H1846_001_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H1846	001	0	1	04	01	H1846_001_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00			
H1846	001	0	1	04	01	H1846_001_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H1846	001	0	1	04	01	H1846_001_0	6	1	4	3	Value Generic	001000	1	2	2	Value Generic	111000000010110000000	30	90								30		30	90								31	1	Value Generic	2	Value Generic																						Value Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H1849	005	0	1	01	01	H1849_005_0	7	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1849	005	0	1	01	01	H1849_005_0	7	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1849	005	0	1	01	01	H1849_005_0	7	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1849	005	0	1	01	01	H1849_005_0	7	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1849	005	0	1	01	01	H1849_005_0	7	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H1849	005	0	1	01	01	H1849_005_0	7	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1849	005	0	1	01	01	H1849_005_0	7	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1849	005	0	1	01	01	H1849_005_0	7	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1849	005	0	1	01	01	H1849_005_0	7	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H1849	005	0	1	01	01	H1849_005_0	7	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H1849	015	0	1	01	01	H1849_015_0	6	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	0.00	0.00								0.00						0.00			0.00		0.00			
H1849	015	0	1	01	01	H1849_015_0	6	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H1849	015	0	1	01	01	H1849_015_0	6	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H1849	015	0	1	01	01	H1849_015_0	6	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H1849	015	0	1	01	01	H1849_015_0	6	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H1849	015	0	1	01	01	H1849_015_0	6	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	0.00	0.00								0.00						0.00			0.00		0.00	1	1	
H1849	015	0	1	01	01	H1849_015_0	6	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H1849	015	0	1	01	01	H1849_015_0	6	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H1849	015	0	1	01	01	H1849_015_0	6	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H1849	015	0	1	01	01	H1849_015_0	6	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H1903	011	0	1	01	01	H1903_011_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H1903	011	0	1	01	01	H1903_011_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H1903	011	0	1	01	01	H1903_011_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H1903	011	0	1	01	01	H1903_011_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H1903	022	0	1	02	01	H1903_022_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H1903	022	0	1	02	01	H1903_022_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H1903	022	0	1	02	01	H1903_022_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H1906	001	0	1	09	04	H1906_001_0	10	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1906	001	0	1	09	04	H1906_001_0	10	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1906	001	0	1	09	04	H1906_001_0	10	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1906	001	0	1	09	04	H1906_001_0	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H1906	001	0	1	09	04	H1906_001_0	10	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1906	001	0	1	09	04	H1906_001_0	10	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1906	001	0	1	09	04	H1906_001_0	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	10	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1906	009	0	1	09	04	H1906_009_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1906	009	0	1	09	04	H1906_009_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1906	009	0	1	09	04	H1906_009_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H1906	009	0	1	09	04	H1906_009_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1906	009	0	1	09	04	H1906_009_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1906	009	0	1	09	04	H1906_009_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1906	009	0	1	09	04	H1906_009_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1906	009	0	1	09	04	H1906_009_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H1944	001	0	1	02	01	H1944_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H1944	001	0	1	02	01	H1944_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H1944	001	0	1	02	01	H1944_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H1944	001	0	1	02	01	H1944_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H1951	001	0	1	01	01	H1951_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H1951	001	0	1	01	01	H1951_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10001000
H1951	001	0	1	01	01	H1951_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H1951	001	0	1	01	01	H1951_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H1951	001	0	1	01	01	H1951_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H1951	001	0	1	01	01	H1951_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1951	001	0	1	01	01	H1951_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	1	
H1951	001	0	1	01	01	H1951_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1951	005	0	1	01	01	H1951_005_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H1951	005	0	1	01	01	H1951_005_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																						1	2	10001000
H1951	005	0	1	01	01	H1951_005_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00	1	2	10000000
H1951	005	0	1	01	01	H1951_005_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00	1	2	10001000
H1951	005	0	1	01	01	H1951_005_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	1	
H1951	005	0	1	01	01	H1951_005_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	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	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00			
H1951	005	0	1	01	01	H1951_005_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H1951	013	0	1	01	01	H1951_013_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1951	013	0	1	01	01	H1951_013_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1951	013	0	1	01	01	H1951_013_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1951	013	0	1	01	01	H1951_013_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1951	013	0	1	01	01	H1951_013_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1951	013	0	1	01	01	H1951_013_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1951	013	0	1	01	01	H1951_013_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1951	017	0	1	01	01	H1951_017_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H1951	017	0	1	01	01	H1951_017_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1951	017	0	1	01	01	H1951_017_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00					95.00	237.50		95.00	285.00		95.00			
H1951	019	0	1	01	01	H1951_019_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1951	019	0	1	01	01	H1951_019_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00					95.00	237.50		95.00	285.00		95.00			
H1951	019	0	1	01	01	H1951_019_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H1951	019	0	1	01	01	H1951_019_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H1951	024	0	1	01	01	H1951_024_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1951	024	0	1	01	01	H1951_024_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1951	024	0	1	01	01	H1951_024_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H1951	024	0	1	01	01	H1951_024_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1951	024	0	1	01	01	H1951_024_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1951	024	0	1	01	01	H1951_024_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1951	024	0	1	01	01	H1951_024_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H1951	024	0	1	01	01	H1951_024_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1951	025	0	1	01	01	H1951_025_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H1951	025	0	1	01	01	H1951_025_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H1951	025	0	1	01	01	H1951_025_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H1951	025	0	1	01	01	H1951_025_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H1951	025	0	1	01	01	H1951_025_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H1951	025	0	1	01	01	H1951_025_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H1951	025	0	1	01	01	H1951_025_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H1951	025	0	1	01	01	H1951_025_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H1961	001	0	1	01	01	H1961_001_0	7	4	4	3	Specialty	100010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1961	001	0	1	01	01	H1961_001_0	7	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	60.00		30.00	90.00		30.00			60.00								30.00			
H1961	001	0	1	01	01	H1961_001_0	7	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	2	Non-Preferred Brand	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	7	4	4	1	Specialty	100010	1	1	2	Specialty	100011011010010000000				30	90		30	90		30			90								31	2	Specialty	1	Specialty				20	20		20	20		20			20								20	Specialty																								
H1961	001	0	1	01	01	H1961_001_0	7	1	4	3	Generic	010000	3	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00	1	1	
H1961	001	0	1	01	01	H1961_001_0	7	2	4	3	Preferred Brand	000001	3	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	60.00		30.00	90.00		30.00			60.00								30.00	1	1	
H1961	001	0	1	01	01	H1961_001_0	7	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1961	001	0	1	01	01	H1961_001_0	7	1	4	1	Generic	010000	3	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00			
H1961	002	0	1	02	01	H1961_002_0	5	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1961	002	0	1	02	01	H1961_002_0	5	4	4	3	Specialty	100010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H1961	002	0	1	02	01	H1961_002_0	5	2	4	3	Preferred Brand	000001	3	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	60.00		30.00	90.00		30.00			60.00								30.00	1	1	
H1961	002	0	1	02	01	H1961_002_0	5	1	4	3	Generic	010000	3	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00	1	1	
H1961	002	0	1	02	01	H1961_002_0	5	4	4	1	Specialty	100010	1	1	2	Specialty	100011011010010000000				30	90		30	90		30			90								31	2	Specialty	1	Specialty				20	20		20	20		20			20								20	Specialty																								
H1961	002	0	1	02	01	H1961_002_0	5	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	2	Non-Preferred Brand	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	5	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	60.00		30.00	90.00		30.00			60.00								30.00			
H1961	002	0	1	02	01	H1961_002_0	5	1	4	1	Generic	010000	3	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00			10.00								5.00			
H1961	007	0	1	02	01	H1961_007_0	6	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H1961	007	0	1	02	01	H1961_007_0	6	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H1961	007	0	1	02	01	H1961_007_0	6	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H1961	007	0	1	02	01	H1961_007_0	6	4	4	1	Specialty	100010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	20	20								20			20								20	Specialty																								
H1961	007	0	1	02	01	H1961_007_0	6	1	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00	1	1	
H1961	007	0	1	02	01	H1961_007_0	6	2	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H1961	007	0	1	02	01	H1961_007_0	6	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H1961	007	0	1	02	01	H1961_007_0	6	4	4	3	Specialty	100010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2001	001	0	1	04	01	H2001_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H2001	001	0	1	04	01	H2001_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2001	001	0	1	04	01	H2001_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H2001	001	0	1	04	01	H2001_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H2012	001	0	1	01	01	H2012_001_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	1	
H2012	001	0	1	01	01	H2012_001_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2012	001	0	1	01	01	H2012_001_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2012	001	0	1	01	01	H2012_001_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2012	001	0	1	01	01	H2012_001_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2012	001	0	1	01	01	H2012_001_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2012	001	0	1	01	01	H2012_001_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2012	001	0	1	01	01	H2012_001_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	002	0	1	01	01	H2012_002_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2012	002	0	1	01	01	H2012_002_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2012	002	0	1	01	01	H2012_002_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2012	002	0	1	01	01	H2012_002_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2012	002	0	1	01	01	H2012_002_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	002	0	1	01	01	H2012_002_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2012	002	0	1	01	01	H2012_002_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2012	002	0	1	01	01	H2012_002_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2012	003	0	1	01	01	H2012_003_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2012	003	0	1	01	01	H2012_003_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2012	003	0	1	01	01	H2012_003_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2012	003	0	1	01	01	H2012_003_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2012	003	0	1	01	01	H2012_003_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	003	0	1	01	01	H2012_003_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2012	003	0	1	01	01	H2012_003_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2012	003	0	1	01	01	H2012_003_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2012	006	0	1	01	01	H2012_006_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	006	0	1	01	01	H2012_006_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2012	006	0	1	01	01	H2012_006_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2012	006	0	1	01	01	H2012_006_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2012	006	0	1	01	01	H2012_006_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2012	006	0	1	01	01	H2012_006_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2012	006	0	1	01	01	H2012_006_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2012	006	0	1	01	01	H2012_006_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2012	007	0	1	01	01	H2012_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2012	007	0	1	01	01	H2012_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2012	007	0	1	01	01	H2012_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2012	007	0	1	01	01	H2012_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2012	007	0	1	01	01	H2012_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2012	007	0	1	01	01	H2012_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2012	007	0	1	01	01	H2012_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	007	0	1	01	01	H2012_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2012	008	0	1	01	01	H2012_008_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2012	008	0	1	01	01	H2012_008_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2012	008	0	1	01	01	H2012_008_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H2012	008	0	1	01	01	H2012_008_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10001000
H2012	008	0	1	01	01	H2012_008_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	1	
H2012	008	0	1	01	01	H2012_008_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	008	0	1	01	01	H2012_008_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00			
H2012	008	0	1	01	01	H2012_008_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H2012	009	0	1	01	01	H2012_009_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2012	009	0	1	01	01	H2012_009_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2012	009	0	1	01	01	H2012_009_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2012	009	0	1	01	01	H2012_009_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2012	009	0	1	01	01	H2012_009_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2012	009	0	1	01	01	H2012_009_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2012	009	0	1	01	01	H2012_009_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2012	009	0	1	01	01	H2012_009_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2029	001	0	1	04	01	H2029_001_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	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	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2029	001	0	1	04	01	H2029_001_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	1	
H2029	001	0	1	04	01	H2029_001_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00	1	2	10001000
H2029	001	0	1	04	01	H2029_001_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10000000
H2029	001	0	1	04	01	H2029_001_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2108	022	0	1	01	01	H2108_022_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2108	022	0	1	01	01	H2108_022_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	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	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	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	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2108	026	0	1	02	01	H2108_026_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H2108	028	0	1	01	01	H2108_028_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	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	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2108	028	0	1	01	01	H2108_028_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H2108	029	0	1	01	01	H2108_029_0	2	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2108	029	0	1	01	01	H2108_029_0	2	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2108	029	0	1	01	01	H2108_029_0	2	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H2108	029	0	1	01	01	H2108_029_0	2	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H2108	029	0	1	01	01	H2108_029_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2108	029	0	1	01	01	H2108_029_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H2108	029	0	1	01	01	H2108_029_0	2	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H2108	029	0	1	01	01	H2108_029_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H2108	029	0	1	01	01	H2108_029_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H2108	029	0	1	01	01	H2108_029_0	2	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H2108	030	0	1	01	01	H2108_030_0	2	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H2108	030	0	1	01	01	H2108_030_0	2	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H2108	030	0	1	01	01	H2108_030_0	2	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2108	030	0	1	01	01	H2108_030_0	2	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H2108	030	0	1	01	01	H2108_030_0	2	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H2108	030	0	1	01	01	H2108_030_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2108	030	0	1	01	01	H2108_030_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H2108	030	0	1	01	01	H2108_030_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H2108	030	0	1	01	01	H2108_030_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00			
H2108	030	0	1	01	01	H2108_030_0	2	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2108	031	0	1	01	01	H2108_031_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H2108	031	0	1	01	01	H2108_031_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H2108	031	0	1	01	01	H2108_031_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00			
H2108	031	0	1	01	01	H2108_031_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2112	007	0	1	01	01	H2112_007_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				78.00	195.00		78.00	234.00			78.00					156.00			234.00		78.00			
H2112	007	0	1	01	01	H2112_007_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				37.00	92.50		37.00	111.00			37.00					74.00			111.00		37.00			
H2112	007	0	1	01	01	H2112_007_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H2112	007	0	1	01	01	H2112_007_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				9.00	22.50		9.00	27.00			9.00					18.00			27.00		9.00			
H2112	007	0	1	01	01	H2112_007_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H2112	014	0	1	01	01	H2112_014_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H2112	014	0	1	01	01	H2112_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																						2		
H2112	014	0	1	01	01	H2112_014_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H2112	014	0	1	01	01	H2112_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																						2		
H2112	014	0	1	01	01	H2112_014_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H2112	014	0	1	01	01	H2112_014_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H2112	014	0	1	01	01	H2112_014_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H2112	014	0	1	01	01	H2112_014_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H2112	014	0	1	01	01	H2112_014_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H2150	002	0	1	18	06	H2150_002_0	4	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H2150	002	0	1	18	06	H2150_002_0	4	1	4	3	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Generic	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00	1	1	
H2150	002	0	1	18	06	H2150_002_0	4	3	4	1	Specialty	000010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				10			15			15											15	Specialty																								
H2150	002	0	1	18	06	H2150_002_0	4	2	4	1	Brand	000010	1	2	1	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Brand	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	4	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2150	002	0	1	18	06	H2150_002_0	4	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Generic	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	4	2	4	1	Brand	000010	1	2	1	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Brand	2	Brand																						Brand				47.00	141.00		63.00	189.00		63.00					42.00	126.00		63.00	189.00		63.00			
H2150	009	0	1	18	06	H2150_009_0	4	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Generic	2	Generic																						Generic				10.00	30.00		30.00	90.00		30.00					7.00	21.00		30.00	90.00		30.00			
H2150	009	0	1	18	06	H2150_009_0	4	3	4	1	Specialty	000010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				25			25			25											25	Specialty																								
H2150	028	0	2	18	06	H2150_028_0	4	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2150	028	0	2	18	06	H2150_028_0	4	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H2150	028	0	2	18	06	H2150_028_0	4	1	4	3	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Generic	2	Generic																						Generic				10.00	30.00		20.00	60.00		20.00					7.00	21.00		20.00	60.00		20.00	1	1	
H2150	028	0	2	18	06	H2150_028_0	4	3	4	1	Specialty	000010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				10			15			15											15	Specialty																								
H2150	028	0	2	18	06	H2150_028_0	4	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Generic	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	4	2	4	1	Brand	000010	1	2	1	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Brand	2	Brand																						Brand				30.00	90.00		55.00	165.00		55.00					25.00	75.00		55.00	165.00		55.00			
H2150	029	0	2	18	06	H2150_029_0	4	2	4	1	Brand	000010	1	2	1	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Brand	2	Brand																						Brand				47.00	141.00		63.00	189.00		63.00					42.00	126.00		63.00	189.00		63.00			
H2150	029	0	2	18	06	H2150_029_0	4	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		31	1	Generic	2	Generic																						Generic				10.00	30.00		30.00	90.00		30.00					7.00	21.00		30.00	90.00		30.00			
H2150	029	0	2	18	06	H2150_029_0	4	3	4	1	Specialty	000010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				25			25			25											25	Specialty																								
H2165	005	0	1	01	01	H2165_005_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2165	005	0	1	01	01	H2165_005_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2165	005	0	1	01	01	H2165_005_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2165	005	0	1	01	01	H2165_005_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H2165	005	0	1	01	01	H2165_005_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H2165	005	0	1	01	01	H2165_005_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H2165	005	0	1	01	01	H2165_005_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H2165	005	0	1	01	01	H2165_005_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2165	005	0	1	01	01	H2165_005_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H2165	005	0	1	01	01	H2165_005_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H2165	006	0	1	01	01	H2165_006_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
H2165	006	0	1	01	01	H2165_006_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50			
H2165	006	0	1	01	01	H2165_006_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2165	006	0	1	01	01	H2165_006_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2165	006	0	1	01	01	H2165_006_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2165	006	0	1	01	01	H2165_006_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50	1	2	01000000
H2165	006	0	1	01	01	H2165_006_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50	1	1	
H2165	006	0	1	01	01	H2165_006_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2165	006	0	1	01	01	H2165_006_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H2165	006	0	1	01	01	H2165_006_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H2165	010	0	1	01	01	H2165_010_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50			
H2165	010	0	1	01	01	H2165_010_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2165	010	0	1	01	01	H2165_010_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2165	010	0	1	01	01	H2165_010_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50	1	1	
H2165	010	0	1	01	01	H2165_010_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2165	010	0	1	01	01	H2165_010_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2165	010	0	1	01	01	H2165_010_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H2165	010	0	1	01	01	H2165_010_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H2165	010	0	1	01	01	H2165_010_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50			
H2165	010	0	1	01	01	H2165_010_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50	1	1	
H2169	002	0	1	01	01	H2169_002_0	2	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H2169	002	0	1	01	01	H2169_002_0	2	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H2169	002	0	1	01	01	H2169_002_0	2	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H2169	002	0	1	01	01	H2169_002_0	2	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H2169	003	0	1	01	01	H2169_003_0	2	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H2169	003	0	1	01	01	H2169_003_0	2	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H2169	003	0	1	01	01	H2169_003_0	2	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H2169	003	0	1	01	01	H2169_003_0	2	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H2169	005	0	1	01	01	H2169_005_0	2	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H2169	005	0	1	01	01	H2169_005_0	2	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H2169	005	0	1	01	01	H2169_005_0	2	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H2169	005	0	1	01	01	H2169_005_0	2	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H2169	006	0	1	01	01	H2169_006_0	3	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H2169	006	0	1	01	01	H2169_006_0	3	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H2169	006	0	1	01	01	H2169_006_0	3	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H2169	006	0	1	01	01	H2169_006_0	3	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H2174	001	0	1	01	01	H2174_001_0	4	2	4	1	Preferred Brand	100001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	90.00								45.00			90.00								45.00			
H2174	001	0	1	01	01	H2174_001_0	4	3	4	1	Specialty	011011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	25									25											25	Specialty																								
H2174	001	0	1	01	01	H2174_001_0	4	4	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	95.00	190.00								95.00			190.00								95.00			
H2174	001	0	1	01	01	H2174_001_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H2174	002	0	1	01	01	H2174_002_0	8	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H2174	002	0	1	01	01	H2174_002_0	8	2	4	3	Preferred Brand	000011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2174	002	0	1	01	01	H2174_002_0	8	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H2174	002	0	1	01	01	H2174_002_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00	1	1	
H2174	002	0	1	01	01	H2174_002_0	8	2	4	1	Preferred Brand	000011	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00			
H2174	002	0	1	01	01	H2174_002_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00			
H2174	006	0	1	01	01	H2174_006_0	4	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H2174	006	0	1	01	01	H2174_006_0	4	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H2174	006	0	1	01	01	H2174_006_0	4	2	4	3	Preferred Brand	000011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2174	006	0	1	01	01	H2174_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00	1	1	
H2174	006	0	1	01	01	H2174_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00			
H2174	006	0	1	01	01	H2174_006_0	4	2	4	1	Preferred Brand	000011	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00			
H2174	007	0	1	01	01	H2174_007_0	4	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H2174	007	0	1	01	01	H2174_007_0	4	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H2174	007	0	1	01	01	H2174_007_0	4	2	4	3	Preferred Brand	000011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2174	007	0	1	01	01	H2174_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00	1	1	
H2174	007	0	1	01	01	H2174_007_0	4	2	4	1	Preferred Brand	000011	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00			
H2174	007	0	1	01	01	H2174_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	18.00								9.00			18.00								9.00			
H2182	001	0	1	02	01	H2182_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2182	001	0	1	02	01	H2182_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	4.00	12.00								4.00						8.00			12.00		4.00			
H2182	001	0	1	02	01	H2182_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H2182	001	0	1	02	01	H2182_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H2228	009	0	1	04	01	H2228_009_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2228	009	0	1	04	01	H2228_009_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H2228	009	0	1	04	01	H2228_009_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H2228	009	0	1	04	01	H2228_009_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H2230	002	0	1	04	01	H2230_002_0	10	4	4	1	Tier 4	110001	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	25	25								25		25	25								25	Tier 4																								
H2230	002	0	1	04	01	H2230_002_0	10	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00		10.00	20.00								10.00			
H2230	002	0	1	04	01	H2230_002_0	10	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00		35.00	70.00								35.00			
H2230	002	0	1	04	01	H2230_002_0	10	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00		65.00	130.00								65.00			
H2237	001	0	1	01	01	H2237_001_0	7	1	3	1	Generic	010000		2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	4.00									4.00											4.00			
H2237	001	0	1	01	01	H2237_001_0	7	2	3	1	Other	010010		2	1	Other	110000000010000000000	30									30											31		Other	2	Other																						Other	47.00									47.00											47.00			
H2237	007	0	1	01	01	H2237_007_0	6	2	3	1	Other	010010		2	1	Other	110000000010000000000	30									30											31		Other	2	Other																						Other	47.00									47.00											47.00			
H2237	007	0	1	01	01	H2237_007_0	6	1	3	1	Generic	010000		2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	2.00									2.00											2.00			
H2241	001	0	1	01	01	H2241_001_0	7	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H2241	001	0	1	01	01	H2241_001_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	90								31			90								31	1	Tier 2	2	Tier 2																						Tier 2	28.00	84.00								28.00			56.00								28.00			
H2241	001	0	1	01	01	H2241_001_0	7	4	4	1	Specialty	101101	1	1	1	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2241	001	0	1	01	01	H2241_001_0	7	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H2241	001	0	1	01	01	H2241_001_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2241	001	0	1	01	01	H2241_001_0	7	3	4	3	Tier 3	100100	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2241	001	0	1	01	01	H2241_001_0	7	4	4	3	Specialty	101101	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H2241	001	0	1	01	01	H2241_001_0	7	3	4	1	Tier 3	100100	1	2	2	Tier 3	111000000010010000000	31	90								31			90								31	1	Tier 3	2	Tier 3																						Tier 3	50.00	150.00								50.00			100.00								50.00			
H2256	001	1	1	01	01	H2256_001_1	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00	1	1	
H2256	001	1	1	01	01	H2256_001_1	6	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00		47.00	140.00	93.00							70.00			
H2256	001	1	1	01	01	H2256_001_1	6	3	4	3	Tier 3	000010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2256	001	1	1	01	01	H2256_001_1	6	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 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	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	6	2	4	3	Tier 2	010010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2256	001	2	1	01	01	H2256_001_2	6	2	4	3	Tier 2	010010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2256	001	2	1	01	01	H2256_001_2	6	3	4	3	Tier 3	000010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2256	001	2	1	01	01	H2256_001_2	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00	1	1	
H2256	001	2	1	01	01	H2256_001_2	6	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00		47.00	140.00	93.00							70.00			
H2256	001	2	1	01	01	H2256_001_2	6	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 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	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	7	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	83.00	249.00	166.00							83.00		55.00	166.00	111.00							83.00			
H2256	015	1	1	01	01	H2256_015_1	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	7	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	42.00	126.00	84.00							42.00		28.00	84.00	56.00							42.00			
H2256	015	2	1	01	01	H2256_015_2	7	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	83.00	249.00	166.00							83.00		55.00	166.00	111.00							83.00			
H2256	015	2	1	01	01	H2256_015_2	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	7	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	42.00	126.00	84.00							42.00		28.00	84.00	56.00							42.00			
H2256	017	1	1	01	01	H2256_017_1	7	1	4	3	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00	1	1	
H2256	017	1	1	01	01	H2256_017_1	7	2	4	3	Tier 2	010010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2256	017	1	1	01	01	H2256_017_1	7	3	4	3	Tier 3	000010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2256	017	1	1	01	01	H2256_017_1	7	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 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	7	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00		47.00	140.00	93.00							70.00			
H2256	017	1	1	01	01	H2256_017_1	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	7	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 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	7	2	4	3	Tier 2	010010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2256	017	7	1	01	01	H2256_017_7	7	3	4	3	Tier 3	000010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2256	017	7	1	01	01	H2256_017_7	7	1	4	3	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00	1	1	
H2256	017	7	1	01	01	H2256_017_7	7	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00		47.00	140.00	93.00							70.00			
H2256	018	1	1	01	01	H2256_018_1	6	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	83.00	249.00	166.00							83.00		55.00	166.00	111.00							83.00			
H2256	018	1	1	01	01	H2256_018_1	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	6	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	42.00	126.00	84.00							42.00		28.00	84.00	56.00							42.00			
H2256	018	7	1	01	01	H2256_018_7	6	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	42.00	126.00	84.00							42.00		28.00	84.00	56.00							42.00			
H2256	018	7	1	01	01	H2256_018_7	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	6	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	83.00	249.00	166.00							83.00		55.00	166.00	111.00							83.00			
H2256	023	0	1	01	01	H2256_023_0	6	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00	140.00							70.00		47.00	140.00	93.00							70.00			
H2256	023	0	1	01	01	H2256_023_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00	1	1	
H2256	023	0	1	01	01	H2256_023_0	6	2	4	3	Tier 2	010010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2256	023	0	1	01	01	H2256_023_0	6	3	4	3	Tier 3	000010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2256	023	0	1	01	01	H2256_023_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	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	6	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		20.00	60.00	40.00							30.00			
H2256	024	0	1	01	01	H2256_024_0	6	3	4	1	Tier 3	000010	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	83.00	249.00	166.00							83.00		55.00	166.00	111.00							83.00			
H2256	024	0	1	01	01	H2256_024_0	6	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	42.00	126.00	84.00							42.00		28.00	84.00	56.00							42.00			
H2256	024	0	1	01	01	H2256_024_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00	20.00							10.00		7.00	20.00	14.00							10.00			
H2312	004	0	1	01	01	H2312_004_0	6	1	4	1	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H2312	004	0	1	01	01	H2312_004_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00			
H2312	004	0	1	01	01	H2312_004_0	6	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00			
H2312	007	0	1	01	01	H2312_007_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	100.00								40.00			100.00								40.00			
H2312	007	0	1	01	01	H2312_007_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	150.00								60.00			150.00								60.00			
H2312	007	0	1	01	01	H2312_007_0	5	1	4	1	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	15.00								6.00			15.00								6.00			
H2312	007	0	1	01	01	H2312_007_0	5	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	150.00								60.00			150.00								60.00			
H2312	009	0	1	01	01	H2312_009_0	5	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00			
H2312	009	0	1	01	01	H2312_009_0	5	1	4	3	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	10.00								4.00			10.00								4.00	1	1	
H2312	009	0	1	01	01	H2312_009_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2312	009	0	1	01	01	H2312_009_0	5	4	4	3	Tier 4	100001	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2312	009	0	1	01	01	H2312_009_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00			
H2312	009	0	1	01	01	H2312_009_0	5	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2312	009	0	1	01	01	H2312_009_0	5	1	4	1	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	10.00								4.00			10.00								4.00			
H2312	009	0	1	01	01	H2312_009_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	7	4	4	3	Tier 4	100001	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2312	010	0	1	01	01	H2312_010_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2312	010	0	1	01	01	H2312_010_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2312	010	0	1	01	01	H2312_010_0	7	1	4	3	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	10.00								4.00			10.00								4.00	1	1	
H2312	010	0	1	01	01	H2312_010_0	7	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	137.50								55.00			137.50								55.00			
H2312	010	0	1	01	01	H2312_010_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00			
H2312	010	0	1	01	01	H2312_010_0	7	1	4	1	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	10.00								4.00			10.00								4.00			
H2312	010	0	1	01	01	H2312_010_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00			
H2319	008	3	1	09	04	H2319_008_3	10	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H2319	008	3	1	09	04	H2319_008_3	10	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	008	3	1	09	04	H2319_008_3	10	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				90.00	225.00		90.00	270.00		90.00					90.00	225.00		90.00	270.00		90.00			
H2319	008	3	1	09	04	H2319_008_3	10	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00					35.00	87.50		35.00	105.00		35.00			
H2319	008	3	1	09	04	H2319_008_3	10	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00					9.00	22.50		9.00	27.00		9.00			
H2319	008	4	1	09	04	H2319_008_4	8	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H2319	008	4	1	09	04	H2319_008_4	8	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00					9.00	22.50		9.00	27.00		9.00			
H2319	008	4	1	09	04	H2319_008_4	8	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00					35.00	87.50		35.00	105.00		35.00			
H2319	008	4	1	09	04	H2319_008_4	8	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				90.00	225.00		90.00	270.00		90.00					90.00	225.00		90.00	270.00		90.00			
H2319	008	4	1	09	04	H2319_008_4	8	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	008	5	1	09	04	H2319_008_5	8	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				90.00	225.00		90.00	270.00		90.00					90.00	225.00		90.00	270.00		90.00			
H2319	008	5	1	09	04	H2319_008_5	8	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	008	5	1	09	04	H2319_008_5	8	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H2319	008	5	1	09	04	H2319_008_5	8	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00					9.00	22.50		9.00	27.00		9.00			
H2319	008	5	1	09	04	H2319_008_5	8	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00					35.00	87.50		35.00	105.00		35.00			
H2319	008	7	1	09	04	H2319_008_7	8	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	008	7	1	09	04	H2319_008_7	8	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				90.00	225.00		90.00	270.00		90.00					90.00	225.00		90.00	270.00		90.00			
H2319	008	7	1	09	04	H2319_008_7	8	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00					35.00	87.50		35.00	105.00		35.00			
H2319	008	7	1	09	04	H2319_008_7	8	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00					9.00	22.50		9.00	27.00		9.00			
H2319	008	7	1	09	04	H2319_008_7	8	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H2319	008	9	1	09	04	H2319_008_9	8	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				90.00	225.00		90.00	270.00		90.00					90.00	225.00		90.00	270.00		90.00			
H2319	008	9	1	09	04	H2319_008_9	8	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H2319	008	9	1	09	04	H2319_008_9	8	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	008	9	1	09	04	H2319_008_9	8	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00					35.00	87.50		35.00	105.00		35.00			
H2319	008	9	1	09	04	H2319_008_9	8	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00					9.00	22.50		9.00	27.00		9.00			
H2319	008	10	1	09	04	H2319_008_10	10	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				9.00	22.50		9.00	27.00		9.00					9.00	22.50		9.00	27.00		9.00			
H2319	008	10	1	09	04	H2319_008_10	10	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00					35.00	87.50		35.00	105.00		35.00			
H2319	008	10	1	09	04	H2319_008_10	10	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				90.00	225.00		90.00	270.00		90.00					90.00	225.00		90.00	270.00		90.00			
H2319	008	10	1	09	04	H2319_008_10	10	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	008	10	1	09	04	H2319_008_10	10	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H2319	009	1	1	09	04	H2319_009_1	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
H2319	009	1	1	09	04	H2319_009_1	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	009	1	1	09	04	H2319_009_1	10	5	4	1	Non Self Administered injectable	010010	1	2	2	Non Self Administered injectable	100010010010000000000				31			31			31											31		Non Self Administered injectable	1	Non Self Administered injectable				25			25			25											25	Non Self Administered injectable																								
H2319	009	1	1	09	04	H2319_009_1	10	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	10	5	4	1	Non Self Administered injectable	010010	1	2	2	Non Self Administered injectable	100010010010000000000				31			31			31											31		Non Self Administered injectable	1	Non Self Administered injectable				25			25			25											25	Non Self Administered injectable																								
H2319	009	2	1	09	04	H2319_009_2	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	009	2	1	09	04	H2319_009_2	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
H2319	009	2	1	09	04	H2319_009_2	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	10	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	10	5	4	1	Non Self Administered injectable	010010	1	2	2	Non Self Administered injectable	100010010010000000000				31			31			31											31		Non Self Administered injectable	1	Non Self Administered injectable				25			25			25											25	Non Self Administered injectable																								
H2319	009	3	1	09	04	H2319_009_3	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
H2319	009	3	1	09	04	H2319_009_3	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	009	3	1	09	04	H2319_009_3	10	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	10	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
H2319	009	4	1	09	04	H2319_009_4	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	009	4	1	09	04	H2319_009_4	10	5	4	1	Non Self Administered injectable	010010	1	2	2	Non Self Administered injectable	100010010010000000000				31			31			31											31		Non Self Administered injectable	1	Non Self Administered injectable				25			25			25											25	Non Self Administered injectable																								
H2319	009	5	1	09	04	H2319_009_5	10	5	4	1	Non Self Administered injectable	010010	1	2	2	Non Self Administered injectable	100010010010000000000				31			31			31											31		Non Self Administered injectable	1	Non Self Administered injectable				25			25			25											25	Non Self Administered injectable																								
H2319	009	5	1	09	04	H2319_009_5	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	009	5	1	09	04	H2319_009_5	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
H2319	009	5	1	09	04	H2319_009_5	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	10	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	13	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	13	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	13	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
H2319	009	6	1	09	04	H2319_009_6	13	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H2319	009	6	1	09	04	H2319_009_6	13	5	4	1	Non Self Administered injectable	010010	1	2	2	Non Self Administered injectable	100010010010000000000				31			31			31											31		Non Self Administered injectable	1	Non Self Administered injectable				25			25			25											25	Non Self Administered injectable																								
H2320	007	0	1	02	01	H2320_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	007	0	1	02	01	H2320_007_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	007	0	1	02	01	H2320_007_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	008	0	1	02	01	H2320_008_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	008	0	1	02	01	H2320_008_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	008	0	1	02	01	H2320_008_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	009	0	1	02	01	H2320_009_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	009	0	1	02	01	H2320_009_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	009	0	1	02	01	H2320_009_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	009	0	1	02	01	H2320_009_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00	1	1	
H2320	009	0	1	02	01	H2320_009_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2320	009	0	1	02	01	H2320_009_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2320	009	0	1	02	01	H2320_009_0	6	4	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H2320	010	0	1	02	01	H2320_010_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2320	010	0	1	02	01	H2320_010_0	6	4	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H2320	010	0	1	02	01	H2320_010_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	010	0	1	02	01	H2320_010_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	010	0	1	02	01	H2320_010_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	010	0	1	02	01	H2320_010_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00	1	1	
H2320	010	0	1	02	01	H2320_010_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2320	011	0	1	02	01	H2320_011_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	011	0	1	02	01	H2320_011_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	011	0	1	02	01	H2320_011_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	011	0	1	02	01	H2320_011_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	012	0	1	02	01	H2320_012_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	012	0	1	02	01	H2320_012_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	013	0	1	02	01	H2320_013_0	8	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	013	0	1	02	01	H2320_013_0	8	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	013	0	1	02	01	H2320_013_0	8	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	014	0	1	02	01	H2320_014_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2320	014	0	1	02	01	H2320_014_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	014	0	1	02	01	H2320_014_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2320	014	0	1	02	01	H2320_014_0	6	4	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H2320	014	0	1	02	01	H2320_014_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00	1	1	
H2320	014	0	1	02	01	H2320_014_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	014	0	1	02	01	H2320_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	015	0	1	02	01	H2320_015_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	015	0	1	02	01	H2320_015_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	015	0	1	02	01	H2320_015_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	015	0	1	02	01	H2320_015_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	016	0	1	02	01	H2320_016_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	016	0	1	02	01	H2320_016_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	017	0	1	02	01	H2320_017_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	017	0	1	02	01	H2320_017_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	017	0	1	02	01	H2320_017_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00	1	1	
H2320	017	0	1	02	01	H2320_017_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2320	017	0	1	02	01	H2320_017_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2320	017	0	1	02	01	H2320_017_0	6	4	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H2320	017	0	1	02	01	H2320_017_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	018	0	1	02	01	H2320_018_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	018	0	1	02	01	H2320_018_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	018	0	1	02	01	H2320_018_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	019	0	1	02	01	H2320_019_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	019	0	1	02	01	H2320_019_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	019	0	1	02	01	H2320_019_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H2320	019	0	1	02	01	H2320_019_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	020	0	1	02	01	H2320_020_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2320	020	0	1	02	01	H2320_020_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2320	020	0	1	02	01	H2320_020_0	6	4	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H2320	020	0	1	02	01	H2320_020_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00	1	1	
H2320	020	0	1	02	01	H2320_020_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2320	020	0	1	02	01	H2320_020_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	020	0	1	02	01	H2320_020_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H2320	020	0	1	02	01	H2320_020_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	021	0	1	02	01	H2320_021_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H2320	021	0	1	02	01	H2320_021_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H2320	021	0	1	02	01	H2320_021_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H2320	021	0	1	02	01	H2320_021_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H2322	001	0	1	04	01	H2322_001_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	150.00								60.00			150.00								60.00			
H2322	001	0	1	04	01	H2322_001_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	100.00								40.00			100.00								40.00			
H2322	001	0	1	04	01	H2322_001_0	6	1	4	1	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	15.00								6.00			15.00								6.00			
H2322	001	0	1	04	01	H2322_001_0	6	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H2322	004	0	1	04	01	H2322_004_0	7	1	4	3	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	10.00								4.00			10.00								4.00	1	1	
H2322	004	0	1	04	01	H2322_004_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2322	004	0	1	04	01	H2322_004_0	7	4	4	3	Tier 4	100001	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2322	004	0	1	04	01	H2322_004_0	7	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H2322	004	0	1	04	01	H2322_004_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	55.00	137.50								55.00			137.50								55.00			
H2322	004	0	1	04	01	H2322_004_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	7	1	4	1	Tier 1	001001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	10.00								4.00			10.00								4.00			
H2322	004	0	1	04	01	H2322_004_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2323	006	0	1	01	01	H2323_006_0	6	1	4	1	generic	010000	1	2	2	generic	111000000001010000000	31	90									29		90								31	1	generic	2	generic																						generic	5.00	10.00									5.00		10.00								5.00			
H2323	006	0	1	01	01	H2323_006_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									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	2	Non-Preferred Brand	111000000001010000000	31	90									29		90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	130.00									65.00		130.00								65.00			
H2323	006	0	1	01	01	H2323_006_0	6	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H2323	006	0	1	01	01	H2323_006_0	6	1	4	3	generic	010000	1	2	2	generic	111000000001010000000	31	90									29		90								31	1	generic	2	generic																						generic	5.00	10.00									5.00		10.00								5.00	1	1	
H2323	006	0	1	01	01	H2323_006_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2323	006	0	1	01	01	H2323_006_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2323	006	0	1	01	01	H2323_006_0	6	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001100000000	31	90									29	31									31	1	Specialty	1	Specialty	33	33									33	33									33	Specialty																								
H2323	007	0	1	01	01	H2323_007_0	6	3	4	1	Non-Preferred	100000	1	2	2	Non-Preferred	111000000001010000000	31	90									29		90								31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	65.00	130.00									65.00		130.00								65.00			
H2323	007	0	1	01	01	H2323_007_0	6	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001010000000	31	90									29		90								31	1	Specialty	1	Specialty	33	33									33		33								33	Specialty																								
H2323	007	0	1	01	01	H2323_007_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00	1	1	
H2323	007	0	1	01	01	H2323_007_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2323	007	0	1	01	01	H2323_007_0	6	3	4	3	Non-Preferred	100000	1	2	2	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H2323	007	0	1	01	01	H2323_007_0	6	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H2323	007	0	1	01	01	H2323_007_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00			
H2323	007	0	1	01	01	H2323_007_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									30.00		60.00								30.00			
H2323	008	0	1	01	01	H2323_008_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00			
H2323	008	0	1	01	01	H2323_008_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									30.00		60.00								30.00			
H2323	008	0	1	01	01	H2323_008_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	31	90									29		90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	130.00									65.00		130.00								65.00			
H2323	008	0	1	01	01	H2323_008_0	7	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H2323	008	0	1	01	01	H2323_008_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00	1	1	
H2323	008	0	1	01	01	H2323_008_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2323	008	0	1	01	01	H2323_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																						2		
H2323	008	0	1	01	01	H2323_008_0	7	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001010000000	31	90									29		90								31	1	Specialty	1	Specialty	33	33									33		33								33	Specialty																								
H2354	001	0	1	01	01	H2354_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	148.00								74.00		74.00	148.00								74.00			
H2354	001	0	1	01	01	H2354_001_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	78.00								39.00		39.00	78.00								39.00			
H2354	001	0	1	01	01	H2354_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	7.00	14.00								7.00		7.00	14.00								7.00			
H2354	001	0	1	01	01	H2354_001_0	4	4	4	1	Specialty	110001	1	1	2	Specialty	110000000010000000000	34									34											34		Specialty	4	Specialty	25									25											25	Specialty	125.00									125.00											125.00			
H2354	013	0	1	01	01	H2354_013_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	6.00	12.00								6.00		6.00	12.00								6.00	1	1	
H2354	013	0	1	01	01	H2354_013_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2354	013	0	1	01	01	H2354_013_0	3	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2354	013	0	1	01	01	H2354_013_0	3	4	4	1	Specialty	110001	1	1	2	Specialty	110000000010000000000	34									34											34		Specialty	4	Specialty	25									25											25	Specialty	125.00									125.00											125.00			
H2354	013	0	1	01	01	H2354_013_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	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	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	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	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	6.00	12.00								6.00		6.00	12.00								6.00			
H2354	013	0	1	01	01	H2354_013_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2410	015	0	1	09	04	H2410_015_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2410	015	0	1	09	04	H2410_015_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2410	015	0	1	09	04	H2410_015_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2410	015	0	1	09	04	H2410_015_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2411	002	0	1	04	01	H2411_002_0	6	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H2411	002	0	1	04	01	H2411_002_0	6	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H2411	002	0	1	04	01	H2411_002_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H2450	001	0	1	18	06	H2450_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	001	0	1	18	06	H2450_001_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	001	0	1	18	06	H2450_001_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	001	0	1	18	06	H2450_001_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	002	0	1	18	06	H2450_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	002	0	1	18	06	H2450_002_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	002	0	1	18	06	H2450_002_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	002	0	1	18	06	H2450_002_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	005	0	1	18	06	H2450_005_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	005	0	1	18	06	H2450_005_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	005	0	1	18	06	H2450_005_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	005	0	1	18	06	H2450_005_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H2450	005	0	1	18	06	H2450_005_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2450	005	0	1	18	06	H2450_005_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	005	0	1	18	06	H2450_005_0	5	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2450	005	0	1	18	06	H2450_005_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2450	006	0	1	18	06	H2450_006_0	5	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2450	006	0	1	18	06	H2450_006_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2450	006	0	1	18	06	H2450_006_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	006	0	1	18	06	H2450_006_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H2450	006	0	1	18	06	H2450_006_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2450	006	0	1	18	06	H2450_006_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	006	0	1	18	06	H2450_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	006	0	1	18	06	H2450_006_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	007	0	1	18	06	H2450_007_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	007	0	1	18	06	H2450_007_0	3	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	007	0	1	18	06	H2450_007_0	3	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	007	0	1	18	06	H2450_007_0	3	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	008	0	1	18	06	H2450_008_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	008	0	1	18	06	H2450_008_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	008	0	1	18	06	H2450_008_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	008	0	1	18	06	H2450_008_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	009	0	1	18	06	H2450_009_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	009	0	1	18	06	H2450_009_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	009	0	1	18	06	H2450_009_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	009	0	1	18	06	H2450_009_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	009	0	1	18	06	H2450_009_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2450	009	0	1	18	06	H2450_009_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H2450	009	0	1	18	06	H2450_009_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2450	009	0	1	18	06	H2450_009_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2450	010	0	1	18	06	H2450_010_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	010	0	1	18	06	H2450_010_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	010	0	1	18	06	H2450_010_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	010	0	1	18	06	H2450_010_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	010	0	1	18	06	H2450_010_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H2450	010	0	1	18	06	H2450_010_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2450	010	0	1	18	06	H2450_010_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2450	010	0	1	18	06	H2450_010_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2450	011	0	1	18	06	H2450_011_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	011	0	1	18	06	H2450_011_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			38.00								34.00			
H2450	011	0	1	18	06	H2450_011_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	011	0	1	18	06	H2450_011_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	012	0	1	18	06	H2450_012_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	012	0	1	18	06	H2450_012_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	012	0	1	18	06	H2450_012_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	012	0	1	18	06	H2450_012_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	013	0	1	18	06	H2450_013_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	013	0	1	18	06	H2450_013_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			68.00								74.00			
H2450	013	0	1	18	06	H2450_013_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	013	0	1	18	06	H2450_013_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	013	0	1	18	06	H2450_013_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H2450	013	0	1	18	06	H2450_013_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2450	013	0	1	18	06	H2450_013_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2450	013	0	1	18	06	H2450_013_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2450	014	0	1	18	06	H2450_014_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	014	0	1	18	06	H2450_014_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2450	014	0	1	18	06	H2450_014_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	014	0	1	18	06	H2450_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	015	0	1	18	06	H2450_015_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2450	015	0	1	18	06	H2450_015_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2450	015	0	1	18	06	H2450_015_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H2450	015	0	1	18	06	H2450_015_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			148.00								74.00			
H2450	015	0	1	18	06	H2450_015_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H2450	015	0	1	18	06	H2450_015_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H2450	015	0	1	18	06	H2450_015_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2450	015	0	1	18	06	H2450_015_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H2459	002	0	1	02	01	H2459_002_0	8	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									29		90								31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00		120.00								60.00			
H2459	002	0	1	02	01	H2459_002_0	8	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000001010000000	30	90									29		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H2459	002	0	1	02	01	H2459_002_0	8	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00	1	1	
H2459	002	0	1	02	01	H2459_002_0	8	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2459	002	0	1	02	01	H2459_002_0	8	3	4	3	Tier 3	000010	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2459	002	0	1	02	01	H2459_002_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									29		90								31	2	Tier 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	8	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2459	002	0	1	02	01	H2459_002_0	8	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00			
H2459	006	0	1	02	01	H2459_006_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00			
H2459	006	0	1	02	01	H2459_006_0	7	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2459	006	0	1	02	01	H2459_006_0	7	3	4	3	Tier 3	000010	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2459	006	0	1	02	01	H2459_006_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2459	006	0	1	02	01	H2459_006_0	7	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00	1	1	
H2459	006	0	1	02	01	H2459_006_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000001010000000	30	90									29		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H2459	006	0	1	02	01	H2459_006_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									29		90								31	2	Tier 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	7	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									29		90								31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00		120.00								60.00			
H2459	013	0	1	02	01	H2459_013_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000001010000000	30	90									29		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H2459	013	0	1	02	01	H2459_013_0	7	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									29		90								31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00		120.00								60.00			
H2459	013	0	1	02	01	H2459_013_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									29		90								31	2	Tier 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	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00			
H2459	014	0	1	02	01	H2459_014_0	7	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									29		90								31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00		120.00								60.00			
H2459	014	0	1	02	01	H2459_014_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									29		90								31	2	Tier 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	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00			
H2459	014	0	1	02	01	H2459_014_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000001010000000	30	90									29		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H2462	008	0	1	18	06	H2462_008_0	4	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00					10.00	20.00		10.00	30.00		10.00			
H2462	008	0	1	18	06	H2462_008_0	4	2	3	1	Formulary Brand	000010		2	1	Formulary Brand	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Brand	2	Formulary Brand																						Formulary Brand	40.00	120.00								40.00					40.00	80.00		40.00	120.00		40.00			
H2462	008	0	1	18	06	H2462_008_0	4	3	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	110000000010000100100	30									30					30			30			31		Formulary Specialty	1	Formulary Specialty	25									25					25			25			25	Formulary Specialty																								
H2462	011	0	1	18	06	H2462_011_0	4	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00					9.00	18.00		9.00	27.00		9.00			
H2462	011	0	1	18	06	H2462_011_0	4	2	3	1	Formulary Brand	000010		2	1	Formulary Brand	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Brand	2	Formulary Brand																						Formulary Brand	40.00	120.00								40.00					40.00	80.00		40.00	120.00		40.00			
H2462	011	0	1	18	06	H2462_011_0	4	3	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	110000000010000100100	30									30					30			30			31		Formulary Specialty	1	Formulary Specialty	25									25					25			25			25	Formulary Specialty																								
H2462	012	0	1	18	06	H2462_012_0	6	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00					10.00	20.00		10.00	30.00		10.00			
H2462	012	0	1	18	06	H2462_012_0	6	2	4	1	Formulary Brand	000010	1	2	1	Formulary Brand	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Brand	2	Formulary Brand																						Formulary Brand	45.00	135.00								45.00					45.00	90.00		45.00	135.00		45.00			
H2462	012	0	1	18	06	H2462_012_0	6	3	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	110000000010000100100	30									30					30			30			31		Formulary Specialty	1	Formulary Specialty	25									25					25			25			25	Formulary Specialty																								
H2462	014	0	1	18	06	H2462_014_0	4	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00					10.00	20.00		10.00	30.00		10.00			
H2462	014	0	1	18	06	H2462_014_0	4	2	4	1	Formulary Brand	000010	1	2	1	Formulary Brand	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Brand	2	Formulary Brand																						Formulary Brand	40.00	120.00								40.00					40.00	80.00		40.00	120.00		40.00			
H2462	014	0	1	18	06	H2462_014_0	4	3	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	110000000010000100100	30									30					30			30			31		Formulary Specialty	1	Formulary Specialty	25									25					25			25			25	Formulary Specialty																								
H2462	014	0	1	18	06	H2462_014_0	4	1	4	3	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010000110110	30	90								30					30	90		30	90		31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00					10.00	20.00		10.00	30.00		10.00	1	1	
H2462	014	0	1	18	06	H2462_014_0	4	2	4	3	Formulary Brand	000010	1	2	1	Formulary Brand																								Formulary Brand		Formulary Brand																						Formulary Brand																						2		
H2462	014	0	1	18	06	H2462_014_0	4	3	4	3	Formulary Specialty	010010	1	1	2	Formulary Specialty																								Formulary Specialty		Formulary Specialty																						Formulary Specialty																						2		
H2481	004	0	1	04	01	H2481_004_0	7	2	4	1	Brand	000011	1	2	2	Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Brand	2	Brand																						Brand				39.00	78.00		39.00	117.00		39.00		39.00	78.00								39.00			
H2481	004	0	1	04	01	H2481_004_0	7	4	4	1	Specialty	100000	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	2	Specialty	1	Specialty				33	33		33	33		33		33	33								33	Specialty																								
H2481	004	0	1	04	01	H2481_004_0	7	3	4	1	Non-preferred Brand	100000	1	2	1	Non-preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand				69.00	138.00		69.00	207.00		69.00		69.00	138.00								69.00			
H2481	004	0	1	04	01	H2481_004_0	7	1	4	1	Generic	011100	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00		5.00	10.00								5.00			
H2486	002	0	1	01	01	H2486_002_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2486	002	0	1	01	01	H2486_002_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2486	002	0	1	01	01	H2486_002_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2486	002	0	1	01	01	H2486_002_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2486	002	0	1	01	01	H2486_002_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2486	002	0	1	01	01	H2486_002_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10000000
H2486	002	0	1	01	01	H2486_002_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2491	001	0	1	01	01	H2491_001_0	6	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H2491	001	0	1	01	01	H2491_001_0	6	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H2491	001	0	1	01	01	H2491_001_0	6	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00			
H2491	001	0	1	01	01	H2491_001_0	6	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H2491	002	0	1	02	01	H2491_002_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H2491	002	0	1	02	01	H2491_002_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
H2491	002	0	1	02	01	H2491_002_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00			
H2491	002	0	1	02	01	H2491_002_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H2542	001	0	1	04	01	H2542_001_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2542	001	0	1	04	01	H2542_001_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2542	001	0	1	04	01	H2542_001_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2542	001	0	1	04	01	H2542_001_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2542	001	0	1	04	01	H2542_001_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2542	001	0	1	04	01	H2542_001_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2542	001	0	1	04	01	H2542_001_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2542	002	0	1	04	01	H2542_002_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2542	002	0	1	04	01	H2542_002_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2542	002	0	1	04	01	H2542_002_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2542	002	0	1	04	01	H2542_002_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2542	002	0	1	04	01	H2542_002_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2542	002	0	1	04	01	H2542_002_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2593	001	0	1	01	01	H2593_001_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H2593	001	0	1	01	01	H2593_001_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H2593	001	0	1	01	01	H2593_001_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H2593	001	0	1	01	01	H2593_001_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H2593	001	0	1	01	01	H2593_001_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H2593	001	0	1	01	01	H2593_001_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs																								Enhanced Care Brand Drugs		Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs																						2		
H2593	001	0	1	01	01	H2593_001_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H2593	001	0	1	01	01	H2593_001_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H2593	001	0	1	01	01	H2593_001_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H2593	001	0	1	01	01	H2593_001_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	65.00	195.00								65.00			130.00								65.00			
H2593	001	0	1	01	01	H2593_001_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H2593	001	0	1	01	01	H2593_001_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	25.00	75.00								25.00			50.00								25.00			
H2593	003	0	1	01	01	H2593_003_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H2593	003	0	1	01	01	H2593_003_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H2593	003	0	1	01	01	H2593_003_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H2593	003	0	1	01	01	H2593_003_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00	1	1	
H2593	003	0	1	01	01	H2593_003_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H2593	003	0	1	01	01	H2593_003_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H2593	003	0	1	01	01	H2593_003_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H2593	003	0	1	01	01	H2593_003_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	65.00	195.00								65.00			130.00								65.00			
H2593	003	0	1	01	01	H2593_003_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H2593	003	0	1	01	01	H2593_003_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00			
H2593	003	0	1	01	01	H2593_003_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H2593	003	0	1	01	01	H2593_003_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H2593	005	0	1	01	01	H2593_005_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H2593	005	0	1	01	01	H2593_005_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H2593	005	0	1	01	01	H2593_005_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00			
H2593	005	0	1	01	01	H2593_005_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H2593	005	0	1	01	01	H2593_005_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	65.00	195.00								65.00			130.00								65.00			
H2593	005	0	1	01	01	H2593_005_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H2593	005	0	1	01	01	H2593_005_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H2593	005	0	1	01	01	H2593_005_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H2593	005	0	1	01	01	H2593_005_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00	1	1	
H2593	005	0	1	01	01	H2593_005_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H2593	005	0	1	01	01	H2593_005_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H2593	005	0	1	01	01	H2593_005_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H2593	006	0	1	01	01	H2593_006_0	6	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H2593	006	0	1	01	01	H2593_006_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H2593	006	0	1	01	01	H2593_006_0	6	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00			
H2593	006	0	1	01	01	H2593_006_0	6	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H2593	006	0	1	01	01	H2593_006_0	6	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	65.00	195.00								65.00			130.00								65.00			
H2593	006	0	1	01	01	H2593_006_0	6	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H2593	006	0	1	01	01	H2593_006_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H2593	006	0	1	01	01	H2593_006_0	6	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H2593	006	0	1	01	01	H2593_006_0	6	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00	1	1	
H2593	006	0	1	01	01	H2593_006_0	6	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H2593	006	0	1	01	01	H2593_006_0	6	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H2593	006	0	1	01	01	H2593_006_0	6	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H2610	005	0	1	01	01	H2610_005_0	5	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H2610	005	0	1	01	01	H2610_005_0	5	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H2610	005	0	1	01	01	H2610_005_0	5	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H2610	005	0	1	01	01	H2610_005_0	5	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	59.00	118.00									59.00	59.00	118.00								59.00			
H2610	006	0	1	01	01	H2610_006_0	4	4	4	3	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H2610	006	0	1	01	01	H2610_006_0	4	2	4	3	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand																								Tier 2 Preferred Brand		Tier 2 Preferred Brand																						Tier 2 Preferred Brand																						2		
H2610	006	0	1	01	01	H2610_006_0	4	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00			
H2610	006	0	1	01	01	H2610_006_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	20.00	40.00									20.00	20.00	40.00								20.00			
H2610	006	0	1	01	01	H2610_006_0	4	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	50.00	100.00									50.00	50.00	100.00								50.00			
H2610	006	0	1	01	01	H2610_006_0	4	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H2610	006	0	1	01	01	H2610_006_0	4	1	4	3	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	2.00	4.00									2.00	2.00	4.00								2.00	1	1	
H2610	006	0	1	01	01	H2610_006_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																						2		
H2610	010	0	1	01	01	H2610_010_0	4	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H2610	010	0	1	01	01	H2610_010_0	4	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	59.00	118.00									59.00	59.00	118.00								59.00			
H2610	010	0	1	01	01	H2610_010_0	4	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H2610	010	0	1	01	01	H2610_010_0	4	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H2610	011	0	1	01	01	H2610_011_0	8	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H2610	011	0	1	01	01	H2610_011_0	8	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H2610	011	0	1	01	01	H2610_011_0	8	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	59.00	118.00									59.00	59.00	118.00								59.00			
H2610	011	0	1	01	01	H2610_011_0	8	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H2611	001	0	1	04	01	H2611_001_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000001000000000	30										29										31		Tier 4	1	Tier 4	25										25										25	Tier 4																								
H2611	001	0	1	04	01	H2611_001_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111100000010010000000	30	90	60							30			90								31	1	Tier 3	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	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00			
H2611	001	0	1	04	01	H2611_001_0	7	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 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	8	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
H2611	002	0	1	04	01	H2611_002_0	8	2	4	3	Tier 2	000010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2611	002	0	1	04	01	H2611_002_0	8	1	4	3	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00	1	1	
H2611	002	0	1	04	01	H2611_002_0	8	4	4	1	4	010010	1	1	2	4	110000000010000000000	30									30											31		4	1	4	25									25											25	4																								
H2611	002	0	1	04	01	H2611_002_0	8	3	4	1	3	100000	1	2	1	3	111100000010010000000	30	90	60							30			90								31	1	3	2	3																						3	70.00	210.00	140.00							70.00			175.00								70.00			
H2611	002	0	1	04	01	H2611_002_0	8	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 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	8	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	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	8	4	4	3	4	010010	1	1	2	4																								4		4																						4																						2		
H2611	008	0	1	04	01	H2611_008_0	5	3	4	1	Tier 3	100010	1	2	1	Tier 3	111100000010010000000	30	90	60							30			90								31	1	Tier 3	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	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	25									25											25	Tier 4																								
H2611	008	0	1	04	01	H2611_008_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	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	5	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 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	8	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2611	012	0	1	04	01	H2611_012_0	8	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	25									25											25	Tier 4																								
H2611	012	0	1	04	01	H2611_012_0	8	1	4	3	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00			12.50								5.00	1	1	
H2611	012	0	1	04	01	H2611_012_0	8	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2611	012	0	1	04	01	H2611_012_0	8	2	4	3	Tier 2	000010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2611	012	0	1	04	01	H2611_012_0	8	3	4	1	Tier 3	100000	1	2	1	Tier 3	111100000010010000000	30	90	60							30			90								31	1	Tier 3	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	8	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 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	8	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00			12.50								5.00			
H2611	016	0	1	04	01	H2611_016_0	9	1	4	3	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00	1	1	
H2611	016	0	1	04	01	H2611_016_0	9	2	4	3	Tier 2	000010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H2611	016	0	1	04	01	H2611_016_0	9	3	4	3	Tier 3	000100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H2611	016	0	1	04	01	H2611_016_0	9	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H2611	016	0	1	04	01	H2611_016_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	25									25											25	Tier 4																								
H2611	016	0	1	04	01	H2611_016_0	9	3	4	1	Tier 3	000100	1	2	1	Tier 3	111100000010010000000	30	90	60							30			90								31	1	Tier 3	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	9	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 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	9	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00			
H2611	018	0	1	04	01	H2611_018_0	10	4	4	1	4	010010	1	1	2	4	110000000010000000000	30									30											31		4	1	4	25									25											25	4																								
H2611	018	0	1	04	01	H2611_018_0	10	3	4	1	3	100000	1	2	1	3	111100000010010000000	30	90	60							30			90								31	1	3	2	3																						3	70.00	210.00	140.00							70.00			175.00								70.00			
H2611	018	0	1	04	01	H2611_018_0	10	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00			17.50								7.00			
H2611	018	0	1	04	01	H2611_018_0	10	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00			87.50								35.00			
H2613	004	0	1	09	04	H2613_004_0	15	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H2613	004	0	1	09	04	H2613_004_0	15	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H2613	004	0	1	09	04	H2613_004_0	15	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H2613	004	0	1	09	04	H2613_004_0	15	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H2613	004	0	1	09	04	H2613_004_0	15	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H2613	004	0	1	09	04	H2613_004_0	15	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H2613	004	0	1	09	04	H2613_004_0	15	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H2613	004	0	1	09	04	H2613_004_0	15	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H2613	004	0	1	09	04	H2613_004_0	15	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H2613	004	0	1	09	04	H2613_004_0	15	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H2643	001	0	1	01	01	H2643_001_0	3	1	4	1	Tier 1 - Generic	011100	1	2	2	Tier 1 - Generic	111100000001010000000	30	90	60								20		90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00	0.00								0.00		0.00								0.00			
H2643	001	0	1	01	01	H2643_001_0	3	2	4	1	Tier 2 - Brand	100011	1	2	1	Tier 2 - Brand	111100000001010000000	30	90	60								20		90								31	2	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	45.00	135.00	135.00								45.00		135.00								45.00			
H2649	004	0	1	01	01	H2649_004_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2649	004	0	1	01	01	H2649_004_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2649	004	0	1	01	01	H2649_004_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2649	004	0	1	01	01	H2649_004_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2649	004	0	1	01	01	H2649_004_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2649	004	0	1	01	01	H2649_004_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2649	004	0	1	01	01	H2649_004_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2649	004	0	1	01	01	H2649_004_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2649	011	0	1	01	01	H2649_011_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2649	011	0	1	01	01	H2649_011_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2649	011	0	1	01	01	H2649_011_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2649	011	0	1	01	01	H2649_011_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2649	011	0	1	01	01	H2649_011_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2649	011	0	1	01	01	H2649_011_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2649	011	0	1	01	01	H2649_011_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2649	011	0	1	01	01	H2649_011_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2649	015	0	1	01	01	H2649_015_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2649	015	0	1	01	01	H2649_015_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2649	015	0	1	01	01	H2649_015_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2649	016	0	1	01	01	H2649_016_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2649	016	0	1	01	01	H2649_016_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2649	016	0	1	01	01	H2649_016_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2649	016	0	1	01	01	H2649_016_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2649	016	0	1	01	01	H2649_016_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2649	016	0	1	01	01	H2649_016_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2649	016	0	1	01	01	H2649_016_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2649	016	0	1	01	01	H2649_016_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2654	004	0	1	01	01	H2654_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2654	004	0	1	01	01	H2654_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H2654	004	0	1	01	01	H2654_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H2654	004	0	1	01	01	H2654_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H2654	010	0	1	02	01	H2654_010_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2654	010	0	1	02	01	H2654_010_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H2654	010	0	1	02	01	H2654_010_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H2654	010	0	1	02	01	H2654_010_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H2654	013	0	1	02	01	H2654_013_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2654	013	0	1	02	01	H2654_013_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H2654	013	0	1	02	01	H2654_013_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H2654	013	0	1	02	01	H2654_013_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H2654	026	0	1	01	01	H2654_026_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H2654	026	0	1	01	01	H2654_026_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H2654	026	0	1	01	01	H2654_026_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H2654	026	0	1	01	01	H2654_026_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2654	027	0	1	01	01	H2654_027_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H2654	027	0	1	01	01	H2654_027_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2654	027	0	1	01	01	H2654_027_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H2654	027	0	1	01	01	H2654_027_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H2663	002	0	1	01	01	H2663_002_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	31.00	93.00								31.00			93.00								31.00			
H2663	002	0	1	01	01	H2663_002_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			18.00								6.00			
H2663	002	0	1	01	01	H2663_002_0	9	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2663	002	0	1	01	01	H2663_002_0	9	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	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	10	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			102.00								34.00			
H2663	005	0	1	01	01	H2663_005_0	10	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2663	005	0	1	01	01	H2663_005_0	10	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H2663	006	0	1	01	01	H2663_006_0	9	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2663	006	0	1	01	01	H2663_006_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H2663	006	0	1	01	01	H2663_006_0	9	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	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	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			102.00								34.00			
H2663	012	0	1	01	01	H2663_012_0	11	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	28.00	84.00								28.00			84.00								28.00			
H2663	012	0	1	01	01	H2663_012_0	11	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
H2663	012	0	1	01	01	H2663_012_0	11	4	3	1	Specialty	010010		1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2663	012	0	1	01	01	H2663_012_0	11	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H2663	013	0	1	01	01	H2663_013_0	8	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2663	013	0	1	01	01	H2663_013_0	8	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H2663	013	0	1	01	01	H2663_013_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			102.00								34.00			
H2663	013	0	1	01	01	H2663_013_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			18.00								6.00			
H2667	003	0	1	01	01	H2667_003_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	25									25											25	Tier 4																								
H2667	003	0	1	01	01	H2667_003_0	7	3	4	1	Tier  3	000100	1	2	1	Tier  3	111100000010010000000	30	90	60							30			90								31	1	Tier  3	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	7	2	4	1	Tier 2	000010	1	2	2	Tier 2	111100000010010000000	30	90	60							30			90								31	1	Tier 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	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010010000000	30	90	60							30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00			12.50								5.00			
H2672	001	0	1	01	01	H2672_001_0	9	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H2672	001	0	1	01	01	H2672_001_0	9	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H2672	001	0	1	01	01	H2672_001_0	9	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	6.00	18.00								6.00			15.00								6.00			
H2672	001	0	1	01	01	H2672_001_0	9	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H2672	003	0	1	01	01	H2672_003_0	12	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H2672	003	0	1	01	01	H2672_003_0	12	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H2672	003	0	1	01	01	H2672_003_0	12	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H2672	003	0	1	01	01	H2672_003_0	12	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H2672	008	0	1	01	01	H2672_008_0	10	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H2672	008	0	1	01	01	H2672_008_0	10	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	6.00	18.00								6.00			15.00								6.00			
H2672	008	0	1	01	01	H2672_008_0	10	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H2672	008	0	1	01	01	H2672_008_0	10	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H2701	001	0	1	04	01	H2701_001_0	6	1	4	3	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	34	90								34		34	90								34	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	10.00	30.00								10.00		10.00	30.00								10.00	1	1	
H2701	001	0	1	04	01	H2701_001_0	6	2	4	3	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand																								Formulary Preferred Brand		Formulary Preferred Brand																						Formulary Preferred Brand																						2		
H2701	001	0	1	04	01	H2701_001_0	6	3	4	3	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand																								Formulary Non-Preferred Brand		Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand																						2		
H2701	001	0	1	04	01	H2701_001_0	6	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2701	001	0	1	04	01	H2701_001_0	6	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	34	90								34		34	90								34	1	Formulary Generic	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	6	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Formulary Preferred Brand	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	6	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Formulary Non-Preferred Brand	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	6	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2701	003	0	1	04	01	H2701_003_0	7	4	4	1	Specialty	010011	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H2701	003	0	1	04	01	H2701_003_0	7	3	4	1	Formulary Non-Preferred Brand	100010	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	70.00	210.00								70.00		70.00	210.00								70.00			
H2701	003	0	1	04	01	H2701_003_0	7	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	34	90								34		34	90								34	1	Formulary Generic	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	7	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00			
H2762	028	0	1	09	04	H2762_028_0	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	028	0	1	09	04	H2762_028_0	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	028	0	1	09	04	H2762_028_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	030	0	1	09	04	H2762_030_0	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	030	0	1	09	04	H2762_030_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	030	0	1	09	04	H2762_030_0	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	032	0	1	09	04	H2762_032_0	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	032	0	1	09	04	H2762_032_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	032	0	1	09	04	H2762_032_0	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	034	0	1	09	04	H2762_034_0	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	034	0	1	09	04	H2762_034_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	034	0	1	09	04	H2762_034_0	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	036	0	1	09	04	H2762_036_0	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	036	0	1	09	04	H2762_036_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	036	0	1	09	04	H2762_036_0	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	038	0	1	09	04	H2762_038_0	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	038	0	1	09	04	H2762_038_0	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	038	0	1	09	04	H2762_038_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	040	0	1	09	04	H2762_040_0	4	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	040	0	1	09	04	H2762_040_0	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	040	0	1	09	04	H2762_040_0	4	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	4	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	042	0	1	09	04	H2762_042_0	3	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	042	0	1	09	04	H2762_042_0	3	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	042	0	1	09	04	H2762_042_0	3	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	042	0	1	09	04	H2762_042_0	3	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	044	0	1	09	04	H2762_044_0	3	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	044	0	1	09	04	H2762_044_0	3	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	044	0	1	09	04	H2762_044_0	3	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	046	0	1	09	04	H2762_046_0	3	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	046	0	1	09	04	H2762_046_0	3	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	048	0	1	09	04	H2762_048_0	3	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	048	0	1	09	04	H2762_048_0	3	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	048	0	1	09	04	H2762_048_0	3	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	048	0	1	09	04	H2762_048_0	3	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	050	0	1	09	04	H2762_050_0	3	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	050	0	1	09	04	H2762_050_0	3	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	050	0	1	09	04	H2762_050_0	3	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00									7.00				7.00	17.50		7.00	21.00		7.00			
H2762	052	0	1	09	04	H2762_052_0	5	3	3	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	052	0	1	09	04	H2762_052_0	5	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	052	0	1	09	04	H2762_052_0	5	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2762	052	0	1	09	04	H2762_052_0	5	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
H2762	054	0	1	09	04	H2762_054_0	3	4	3	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
H2762	054	0	1	09	04	H2762_054_0	3	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	2	3	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
H2773	001	0	1	01	01	H2773_001_0	6	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H2773	001	0	1	01	01	H2773_001_0	6	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	60.00								30.00			
H2773	001	0	1	01	01	H2773_001_0	6	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	55.00	165.00								55.00											55.00			
H2773	001	0	1	01	01	H2773_001_0	6	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H2773	001	0	1	01	01	H2773_001_0	6	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2773	001	0	1	01	01	H2773_001_0	6	1	4	3	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H2773	001	0	1	01	01	H2773_001_0	6	2	4	3	Preferred Brand	000101	3	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2773	001	0	1	01	01	H2773_001_0	6	3	4	3	Brand	100010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H2773	001	0	1	01	01	H2773_001_0	6	4	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2773	001	0	1	01	01	H2773_001_0	6	5	4	3	Specialty	101100	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2773	002	0	1	01	01	H2773_002_0	6	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H2773	002	0	1	01	01	H2773_002_0	6	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H2773	002	0	1	01	01	H2773_002_0	6	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	60.00								30.00			
H2773	002	0	1	01	01	H2773_002_0	6	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	55.00	165.00								55.00											55.00			
H2773	002	0	1	01	01	H2773_002_0	6	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2773	003	0	1	01	01	H2773_003_0	5	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H2773	003	0	1	01	01	H2773_003_0	5	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00			
H2773	003	0	1	01	01	H2773_003_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	55.00	165.00								55.00											55.00			
H2773	003	0	1	01	01	H2773_003_0	5	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H2773	003	0	1	01	01	H2773_003_0	5	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2773	005	0	1	01	01	H2773_005_0	5	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2773	005	0	1	01	01	H2773_005_0	5	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H2773	005	0	1	01	01	H2773_005_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	60.00	180.00								60.00											60.00			
H2773	005	0	1	01	01	H2773_005_0	5	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H2773	005	0	1	01	01	H2773_005_0	5	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H2773	006	0	1	01	01	H2773_006_0	6	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H2773	006	0	1	01	01	H2773_006_0	6	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	60.00	180.00								60.00											60.00			
H2773	006	0	1	01	01	H2773_006_0	6	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	60.00								30.00			
H2773	006	0	1	01	01	H2773_006_0	6	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H2773	006	0	1	01	01	H2773_006_0	6	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	076	0	1	04	01	H2775_076_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	076	0	1	04	01	H2775_076_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	076	0	1	04	01	H2775_076_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	076	0	1	04	01	H2775_076_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	077	0	1	04	01	H2775_077_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	077	0	1	04	01	H2775_077_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	077	0	1	04	01	H2775_077_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	077	0	1	04	01	H2775_077_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	078	0	1	04	01	H2775_078_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	078	0	1	04	01	H2775_078_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	078	0	1	04	01	H2775_078_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	078	0	1	04	01	H2775_078_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	079	0	1	04	01	H2775_079_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	079	0	1	04	01	H2775_079_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	079	0	1	04	01	H2775_079_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	079	0	1	04	01	H2775_079_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	080	0	1	04	01	H2775_080_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	080	0	1	04	01	H2775_080_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	080	0	1	04	01	H2775_080_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	080	0	1	04	01	H2775_080_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	081	0	1	04	01	H2775_081_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	081	0	1	04	01	H2775_081_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	081	0	1	04	01	H2775_081_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	081	0	1	04	01	H2775_081_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	082	0	1	04	01	H2775_082_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2775	082	0	1	04	01	H2775_082_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H2775	082	0	1	04	01	H2775_082_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	082	0	1	04	01	H2775_082_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2775	082	0	1	04	01	H2775_082_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	082	0	1	04	01	H2775_082_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	082	0	1	04	01	H2775_082_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	082	0	1	04	01	H2775_082_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H2775	083	0	1	04	01	H2775_083_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	083	0	1	04	01	H2775_083_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	083	0	1	04	01	H2775_083_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	083	0	1	04	01	H2775_083_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H2775	083	0	1	04	01	H2775_083_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2775	083	0	1	04	01	H2775_083_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2775	083	0	1	04	01	H2775_083_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H2775	083	0	1	04	01	H2775_083_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	084	0	1	04	01	H2775_084_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	084	0	1	04	01	H2775_084_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	084	0	1	04	01	H2775_084_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	084	0	1	04	01	H2775_084_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H2775	084	0	1	04	01	H2775_084_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2775	084	0	1	04	01	H2775_084_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2775	084	0	1	04	01	H2775_084_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	084	0	1	04	01	H2775_084_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H2775	085	0	1	04	01	H2775_085_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H2775	085	0	1	04	01	H2775_085_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2775	085	0	1	04	01	H2775_085_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2775	085	0	1	04	01	H2775_085_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H2775	085	0	1	04	01	H2775_085_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	085	0	1	04	01	H2775_085_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	085	0	1	04	01	H2775_085_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	085	0	1	04	01	H2775_085_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	086	0	1	04	01	H2775_086_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H2775	086	0	1	04	01	H2775_086_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2775	086	0	1	04	01	H2775_086_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2775	086	0	1	04	01	H2775_086_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H2775	086	0	1	04	01	H2775_086_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	086	0	1	04	01	H2775_086_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	086	0	1	04	01	H2775_086_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	086	0	1	04	01	H2775_086_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	087	0	1	04	01	H2775_087_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	087	0	1	04	01	H2775_087_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	087	0	1	04	01	H2775_087_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H2775	087	0	1	04	01	H2775_087_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2775	087	0	1	04	01	H2775_087_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2775	087	0	1	04	01	H2775_087_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H2775	087	0	1	04	01	H2775_087_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	087	0	1	04	01	H2775_087_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	088	0	1	04	01	H2775_088_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	088	0	1	04	01	H2775_088_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	088	0	1	04	01	H2775_088_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	088	0	1	04	01	H2775_088_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	089	0	1	04	01	H2775_089_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	089	0	1	04	01	H2775_089_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	089	0	1	04	01	H2775_089_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	089	0	1	04	01	H2775_089_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	090	0	1	04	01	H2775_090_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	090	0	1	04	01	H2775_090_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	090	0	1	04	01	H2775_090_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	090	0	1	04	01	H2775_090_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	091	0	1	04	01	H2775_091_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	091	0	1	04	01	H2775_091_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	091	0	1	04	01	H2775_091_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	091	0	1	04	01	H2775_091_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	092	0	1	04	01	H2775_092_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2775	092	0	1	04	01	H2775_092_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	092	0	1	04	01	H2775_092_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	092	0	1	04	01	H2775_092_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	093	0	1	04	01	H2775_093_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H2775	093	0	1	04	01	H2775_093_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H2775	093	0	1	04	01	H2775_093_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H2775	093	0	1	04	01	H2775_093_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H2802	001	0	1	02	01	H2802_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H2802	001	0	1	02	01	H2802_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H2802	001	0	1	02	01	H2802_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H2802	001	0	1	02	01	H2802_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2803	001	0	1	02	01	H2803_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H2803	001	0	1	02	01	H2803_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H2803	001	0	1	02	01	H2803_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2803	001	0	1	02	01	H2803_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H2803	002	0	1	02	01	H2803_002_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H2803	002	0	1	02	01	H2803_002_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H2803	002	0	1	02	01	H2803_002_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H2803	002	0	1	02	01	H2803_002_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H2810	001	0	1	04	01	H2810_001_0	13	3	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																								
H2810	001	0	1	04	01	H2810_001_0	13	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00		6.00	18.00								6.00			
H2810	001	0	1	04	01	H2810_001_0	13	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	17.00	51.00								17.00		17.00	51.00								17.00			
H2810	002	0	1	04	01	H2810_002_0	13	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																								
H2810	002	0	1	04	01	H2810_002_0	13	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	45.00								15.00			
H2810	002	0	1	04	01	H2810_002_0	13	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00		9.00	27.00								9.00			
H2899	001	0	1	01	01	H2899_001_0	10	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H2899	001	0	1	01	01	H2899_001_0	10	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H2899	001	0	1	01	01	H2899_001_0	10	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H2899	001	0	1	01	01	H2899_001_0	10	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H2899	001	0	1	01	01	H2899_001_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																						2		
H2899	001	0	1	01	01	H2899_001_0	10	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H2899	001	0	1	01	01	H2899_001_0	10	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H2899	001	0	1	01	01	H2899_001_0	10	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H2899	001	0	1	01	01	H2899_001_0	10	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	5.00	15.00								5.00			10.00								5.00			
H2899	001	0	1	01	01	H2899_001_0	10	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H2899	003	0	1	01	01	H2899_003_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H2899	003	0	1	01	01	H2899_003_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H2899	003	0	1	01	01	H2899_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H2899	003	0	1	01	01	H2899_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H2899	003	0	1	01	01	H2899_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H2899	003	0	1	01	01	H2899_003_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H2899	003	0	1	01	01	H2899_003_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H2899	003	0	1	01	01	H2899_003_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																						2		
H2899	003	0	1	01	01	H2899_003_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H2899	003	0	1	01	01	H2899_003_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H2899	004	0	1	01	01	H2899_004_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H2899	004	0	1	01	01	H2899_004_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H2899	004	0	1	01	01	H2899_004_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H2899	004	0	1	01	01	H2899_004_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H2899	004	0	1	01	01	H2899_004_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H2899	004	0	1	01	01	H2899_004_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H2899	004	0	1	01	01	H2899_004_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H2899	004	0	1	01	01	H2899_004_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																						2		
H2899	004	0	1	01	01	H2899_004_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H2899	004	0	1	01	01	H2899_004_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H2899	006	0	1	01	01	H2899_006_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H2899	006	0	1	01	01	H2899_006_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H2899	006	0	1	01	01	H2899_006_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H2899	006	0	1	01	01	H2899_006_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H2899	006	0	1	01	01	H2899_006_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H2899	006	0	1	01	01	H2899_006_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H2899	006	0	1	01	01	H2899_006_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H2899	006	0	1	01	01	H2899_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																						2		
H2899	006	0	1	01	01	H2899_006_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H2899	006	0	1	01	01	H2899_006_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H2899	009	0	1	01	01	H2899_009_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H2899	009	0	1	01	01	H2899_009_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H2899	009	0	1	01	01	H2899_009_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H2899	009	0	1	01	01	H2899_009_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H2899	009	0	1	01	01	H2899_009_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																						2		
H2899	009	0	1	01	01	H2899_009_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H2899	009	0	1	01	01	H2899_009_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H2899	009	0	1	01	01	H2899_009_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H2899	009	0	1	01	01	H2899_009_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H2899	009	0	1	01	01	H2899_009_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H2905	001	0	1	04	01	H2905_001_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2905	001	0	1	04	01	H2905_001_0	9	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00	1	1	
H2905	001	0	1	04	01	H2905_001_0	9	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2905	001	0	1	04	01	H2905_001_0	9	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	110000000010000000000	30									30											31		Non-Preferred	2	Non-Preferred																						Non-Preferred	85.00									85.00											85.00			
H2905	001	0	1	04	01	H2905_001_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			80.00								40.00			
H2905	001	0	1	04	01	H2905_001_0	9	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00			
H2905	001	0	1	04	01	H2905_001_0	9	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2905	001	0	1	04	01	H2905_001_0	9	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H2906	003	0	1	04	01	H2906_003_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00			87.50								35.00			
H2906	003	0	1	04	01	H2906_003_0	6	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00			
H2906	003	0	1	04	01	H2906_003_0	6	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00			
H2906	003	0	1	04	01	H2906_003_0	6	5	4	3	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical																								Special Pharmaceutical		Special Pharmaceutical																						Special Pharmaceutical																						2		
H2906	003	0	1	04	01	H2906_003_0	6	4	4	3	Non- Preferred Brand Name	100000	1	2	1	Non- Preferred Brand Name																								Non- Preferred Brand Name		Non- Preferred Brand Name																						Non- Preferred Brand Name																						2		
H2906	003	0	1	04	01	H2906_003_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00			87.50								35.00	1	1	
H2906	003	0	1	04	01	H2906_003_0	6	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00	1	1	
H2906	003	0	1	04	01	H2906_003_0	6	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00	1	1	
H2906	003	0	1	04	01	H2906_003_0	6	4	4	1	Non- Preferred Brand Name	100000	1	2	1	Non- Preferred Brand Name	111000000010010000000	30	90								30			90								31	1	Non- Preferred Brand Name	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	6	5	4	1	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical	111000000010010000000	30	90								30			90								31	1	Special Pharmaceutical	1	Special Pharmaceutical	33	33								33			33								33	Special Pharmaceutical																								
H2931	002	0	1	02	01	H2931_002_0	9	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00			
H2931	002	0	1	02	01	H2931_002_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H2931	002	0	1	02	01	H2931_002_0	9	6	4	3	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand																								Special Coverage - Brand		Special Coverage - Brand																						Special Coverage - Brand																						2		
H2931	002	0	1	02	01	H2931_002_0	9	5	4	3	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00	1	1	
H2931	002	0	1	02	01	H2931_002_0	9	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2931	002	0	1	02	01	H2931_002_0	9	3	4	3	Non-preferred	100100	1	2	1	Non-preferred																								Non-preferred		Non-preferred																						Non-preferred																						2		
H2931	002	0	1	02	01	H2931_002_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00	1	1	
H2931	002	0	1	02	01	H2931_002_0	9	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00	1	1	
H2931	002	0	1	02	01	H2931_002_0	9	6	4	1	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand	110000000010000000000	30									30											31		Special Coverage - Brand	2	Special Coverage - Brand																						Special Coverage - Brand	35.00									35.00											35.00			
H2931	002	0	1	02	01	H2931_002_0	9	5	4	1	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00			
H2931	002	0	1	02	01	H2931_002_0	9	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2931	002	0	1	02	01	H2931_002_0	9	3	4	1	Non-preferred	100100	1	2	1	Non-preferred	110000000010000000000	30									30											31		Non-preferred	2	Non-preferred																						Non-preferred	85.00									85.00											85.00			
H2931	004	0	1	01	01	H2931_004_0	7	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00			
H2931	004	0	1	01	01	H2931_004_0	7	5	4	3	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00	1	1	
H2931	004	0	1	01	01	H2931_004_0	7	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2931	004	0	1	01	01	H2931_004_0	7	3	4	3	Non-preferred	100100	1	2	1	Non-preferred																								Non-preferred		Non-preferred																						Non-preferred																						2		
H2931	004	0	1	01	01	H2931_004_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2931	004	0	1	01	01	H2931_004_0	7	6	4	3	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand																								Special Coverage - Brand		Special Coverage - Brand																						Special Coverage - Brand																						2		
H2931	004	0	1	01	01	H2931_004_0	7	6	4	1	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand	110000000010000000000	30									30											31		Special Coverage - Brand	2	Special Coverage - Brand																						Special Coverage - Brand	35.00									35.00											35.00			
H2931	004	0	1	01	01	H2931_004_0	7	5	4	1	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00			
H2931	004	0	1	01	01	H2931_004_0	7	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2931	004	0	1	01	01	H2931_004_0	7	3	4	1	Non-preferred	100100	1	2	1	Non-preferred	110000000010000000000	30									30											31		Non-preferred	2	Non-preferred																						Non-preferred	85.00									85.00											85.00			
H2931	004	0	1	01	01	H2931_004_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H2931	004	0	1	01	01	H2931_004_0	7	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00	1	1	
H2931	015	0	1	01	01	H2931_015_0	5	6	4	3	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	10.00									10.00											10.00	1	1	
H2931	015	0	1	01	01	H2931_015_0	5	7	4	3	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand																								Special Coverage - Brand		Special Coverage - Brand																						Special Coverage - Brand																						2		
H2931	015	0	1	01	01	H2931_015_0	5	5	4	3	Special Coverage - Vitamins	010010	2	2	2	Special Coverage - Vitamins	110000000010000000000	30									30											31		Special Coverage - Vitamins	2	Special Coverage - Vitamins																						Special Coverage - Vitamins	0.00									0.00											0.00	1	1	
H2931	015	0	1	01	01	H2931_015_0	5	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2931	015	0	1	01	01	H2931_015_0	5	3	4	3	Non-preferred	100100	1	2	1	Non-preferred																								Non-preferred		Non-preferred																						Non-preferred																						2		
H2931	015	0	1	01	01	H2931_015_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00	1	2	10000000
H2931	015	0	1	01	01	H2931_015_0	5	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00	1	1	
H2931	015	0	1	01	01	H2931_015_0	5	7	4	1	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand	110000000010000000000	30									30											31		Special Coverage - Brand	2	Special Coverage - Brand																						Special Coverage - Brand	30.00									30.00											30.00			
H2931	015	0	1	01	01	H2931_015_0	5	6	4	1	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	10.00									10.00											10.00			
H2931	015	0	1	01	01	H2931_015_0	5	5	4	1	Special Coverage - Vitamins	010010	2	2	2	Special Coverage - Vitamins	110000000010000000000	30									30											31		Special Coverage - Vitamins	2	Special Coverage - Vitamins																						Special Coverage - Vitamins	0.00									0.00											0.00			
H2931	015	0	1	01	01	H2931_015_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2931	015	0	1	01	01	H2931_015_0	5	3	4	1	Non-preferred	100100	1	2	1	Non-preferred	110000000010000000000	30									30											31		Non-preferred	2	Non-preferred																						Non-preferred	85.00									85.00											85.00			
H2931	015	0	1	01	01	H2931_015_0	5	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	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	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H2931	016	0	1	01	01	H2931_016_0	7	6	4	3	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand																								Special Coverage - Brand		Special Coverage - Brand																						Special Coverage - Brand																						2		
H2931	016	0	1	01	01	H2931_016_0	7	5	4	3	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00	1	1	
H2931	016	0	1	01	01	H2931_016_0	7	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2931	016	0	1	01	01	H2931_016_0	7	3	4	3	Non-preferred	100100	1	2	1	Non-preferred																								Non-preferred		Non-preferred																						Non-preferred																						2		
H2931	016	0	1	01	01	H2931_016_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00	1	1	
H2931	016	0	1	01	01	H2931_016_0	7	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00			
H2931	016	0	1	01	01	H2931_016_0	7	6	4	1	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand	110000000010000000000	30									30											31		Special Coverage - Brand	2	Special Coverage - Brand																						Special Coverage - Brand	35.00									35.00											35.00			
H2931	016	0	1	01	01	H2931_016_0	7	5	4	1	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00			
H2931	016	0	1	01	01	H2931_016_0	7	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2931	016	0	1	01	01	H2931_016_0	7	3	4	1	Non-preferred	100100	1	2	1	Non-preferred	110000000010000000000	30									30											31		Non-preferred	2	Non-preferred																						Non-preferred	85.00									85.00											85.00			
H2931	016	0	1	01	01	H2931_016_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H2931	016	0	1	01	01	H2931_016_0	7	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00	1	1	
H2944	002	0	1	09	04	H2944_002_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	002	0	1	09	04	H2944_002_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	002	0	1	09	04	H2944_002_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	002	0	1	09	04	H2944_002_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	002	0	1	09	04	H2944_002_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	002	0	1	09	04	H2944_002_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	002	0	1	09	04	H2944_002_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	002	0	1	09	04	H2944_002_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	003	0	1	09	04	H2944_003_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	003	0	1	09	04	H2944_003_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	003	0	1	09	04	H2944_003_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	003	0	1	09	04	H2944_003_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	003	0	1	09	04	H2944_003_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	003	0	1	09	04	H2944_003_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	003	0	1	09	04	H2944_003_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	003	0	1	09	04	H2944_003_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	004	0	1	09	04	H2944_004_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	004	0	1	09	04	H2944_004_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	004	0	1	09	04	H2944_004_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	004	0	1	09	04	H2944_004_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	004	0	1	09	04	H2944_004_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	004	0	1	09	04	H2944_004_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	004	0	1	09	04	H2944_004_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	004	0	1	09	04	H2944_004_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	005	0	1	09	04	H2944_005_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	005	0	1	09	04	H2944_005_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	005	0	1	09	04	H2944_005_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	005	0	1	09	04	H2944_005_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	005	0	1	09	04	H2944_005_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	005	0	1	09	04	H2944_005_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	005	0	1	09	04	H2944_005_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	005	0	1	09	04	H2944_005_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	006	0	1	09	04	H2944_006_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	006	0	1	09	04	H2944_006_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	006	0	1	09	04	H2944_006_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	006	0	1	09	04	H2944_006_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	006	0	1	09	04	H2944_006_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	006	0	1	09	04	H2944_006_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	006	0	1	09	04	H2944_006_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	006	0	1	09	04	H2944_006_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	007	0	1	09	04	H2944_007_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	007	0	1	09	04	H2944_007_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	007	0	1	09	04	H2944_007_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	007	0	1	09	04	H2944_007_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	007	0	1	09	04	H2944_007_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	007	0	1	09	04	H2944_007_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	007	0	1	09	04	H2944_007_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	007	0	1	09	04	H2944_007_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	008	0	1	09	04	H2944_008_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	008	0	1	09	04	H2944_008_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	008	0	1	09	04	H2944_008_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	008	0	1	09	04	H2944_008_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	008	0	1	09	04	H2944_008_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	008	0	1	09	04	H2944_008_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	008	0	1	09	04	H2944_008_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	008	0	1	09	04	H2944_008_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	009	0	1	09	04	H2944_009_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	009	0	1	09	04	H2944_009_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	009	0	1	09	04	H2944_009_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	009	0	1	09	04	H2944_009_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	009	0	1	09	04	H2944_009_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	009	0	1	09	04	H2944_009_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	009	0	1	09	04	H2944_009_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	009	0	1	09	04	H2944_009_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	010	0	1	09	04	H2944_010_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	010	0	1	09	04	H2944_010_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	010	0	1	09	04	H2944_010_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	010	0	1	09	04	H2944_010_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	010	0	1	09	04	H2944_010_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	010	0	1	09	04	H2944_010_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	010	0	1	09	04	H2944_010_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	010	0	1	09	04	H2944_010_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	011	0	1	09	04	H2944_011_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	011	0	1	09	04	H2944_011_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	011	0	1	09	04	H2944_011_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	011	0	1	09	04	H2944_011_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	011	0	1	09	04	H2944_011_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	011	0	1	09	04	H2944_011_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	011	0	1	09	04	H2944_011_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	011	0	1	09	04	H2944_011_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	012	0	1	09	04	H2944_012_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	012	0	1	09	04	H2944_012_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	012	0	1	09	04	H2944_012_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	012	0	1	09	04	H2944_012_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	012	0	1	09	04	H2944_012_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	012	0	1	09	04	H2944_012_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	012	0	1	09	04	H2944_012_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	012	0	1	09	04	H2944_012_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	013	0	1	09	04	H2944_013_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	013	0	1	09	04	H2944_013_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	013	0	1	09	04	H2944_013_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	013	0	1	09	04	H2944_013_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	013	0	1	09	04	H2944_013_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	013	0	1	09	04	H2944_013_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	013	0	1	09	04	H2944_013_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	013	0	1	09	04	H2944_013_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	014	0	1	09	04	H2944_014_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	014	0	1	09	04	H2944_014_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	014	0	1	09	04	H2944_014_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	014	0	1	09	04	H2944_014_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	014	0	1	09	04	H2944_014_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	014	0	1	09	04	H2944_014_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	014	0	1	09	04	H2944_014_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	014	0	1	09	04	H2944_014_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	015	0	1	09	04	H2944_015_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	015	0	1	09	04	H2944_015_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	015	0	1	09	04	H2944_015_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	015	0	1	09	04	H2944_015_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	015	0	1	09	04	H2944_015_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	015	0	1	09	04	H2944_015_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	015	0	1	09	04	H2944_015_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	015	0	1	09	04	H2944_015_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	016	0	1	09	04	H2944_016_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	016	0	1	09	04	H2944_016_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	016	0	1	09	04	H2944_016_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	016	0	1	09	04	H2944_016_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	016	0	1	09	04	H2944_016_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	016	0	1	09	04	H2944_016_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	016	0	1	09	04	H2944_016_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	016	0	1	09	04	H2944_016_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	017	0	1	09	04	H2944_017_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	017	0	1	09	04	H2944_017_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	017	0	1	09	04	H2944_017_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	017	0	1	09	04	H2944_017_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	017	0	1	09	04	H2944_017_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	017	0	1	09	04	H2944_017_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	017	0	1	09	04	H2944_017_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	017	0	1	09	04	H2944_017_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	019	0	1	09	04	H2944_019_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	019	0	1	09	04	H2944_019_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	019	0	1	09	04	H2944_019_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	019	0	1	09	04	H2944_019_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	019	0	1	09	04	H2944_019_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	019	0	1	09	04	H2944_019_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	019	0	1	09	04	H2944_019_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	019	0	1	09	04	H2944_019_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	020	0	1	09	04	H2944_020_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	020	0	1	09	04	H2944_020_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	020	0	1	09	04	H2944_020_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	020	0	1	09	04	H2944_020_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	020	0	1	09	04	H2944_020_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	020	0	1	09	04	H2944_020_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	020	0	1	09	04	H2944_020_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	020	0	1	09	04	H2944_020_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	021	0	1	09	04	H2944_021_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	021	0	1	09	04	H2944_021_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	021	0	1	09	04	H2944_021_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	021	0	1	09	04	H2944_021_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	021	0	1	09	04	H2944_021_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	021	0	1	09	04	H2944_021_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	021	0	1	09	04	H2944_021_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	021	0	1	09	04	H2944_021_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	022	0	1	09	04	H2944_022_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	022	0	1	09	04	H2944_022_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	022	0	1	09	04	H2944_022_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	022	0	1	09	04	H2944_022_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	022	0	1	09	04	H2944_022_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	022	0	1	09	04	H2944_022_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	022	0	1	09	04	H2944_022_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	022	0	1	09	04	H2944_022_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	023	0	1	09	04	H2944_023_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	023	0	1	09	04	H2944_023_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	023	0	1	09	04	H2944_023_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	023	0	1	09	04	H2944_023_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	023	0	1	09	04	H2944_023_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	023	0	1	09	04	H2944_023_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	023	0	1	09	04	H2944_023_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	023	0	1	09	04	H2944_023_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	024	0	1	09	04	H2944_024_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	024	0	1	09	04	H2944_024_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	024	0	1	09	04	H2944_024_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	024	0	1	09	04	H2944_024_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	024	0	1	09	04	H2944_024_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	024	0	1	09	04	H2944_024_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	024	0	1	09	04	H2944_024_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	024	0	1	09	04	H2944_024_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	026	0	1	09	04	H2944_026_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	026	0	1	09	04	H2944_026_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	026	0	1	09	04	H2944_026_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	026	0	1	09	04	H2944_026_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	026	0	1	09	04	H2944_026_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	026	0	1	09	04	H2944_026_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	026	0	1	09	04	H2944_026_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	026	0	1	09	04	H2944_026_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	027	0	1	09	04	H2944_027_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	027	0	1	09	04	H2944_027_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	027	0	1	09	04	H2944_027_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	027	0	1	09	04	H2944_027_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	027	0	1	09	04	H2944_027_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	027	0	1	09	04	H2944_027_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	027	0	1	09	04	H2944_027_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	027	0	1	09	04	H2944_027_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	028	0	1	09	04	H2944_028_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	028	0	1	09	04	H2944_028_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	028	0	1	09	04	H2944_028_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	028	0	1	09	04	H2944_028_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	028	0	1	09	04	H2944_028_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	028	0	1	09	04	H2944_028_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	028	0	1	09	04	H2944_028_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	028	0	1	09	04	H2944_028_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	029	0	1	09	04	H2944_029_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	029	0	1	09	04	H2944_029_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	029	0	1	09	04	H2944_029_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	029	0	1	09	04	H2944_029_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	029	0	1	09	04	H2944_029_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	029	0	1	09	04	H2944_029_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	029	0	1	09	04	H2944_029_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	029	0	1	09	04	H2944_029_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	030	0	1	09	04	H2944_030_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	030	0	1	09	04	H2944_030_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	030	0	1	09	04	H2944_030_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	030	0	1	09	04	H2944_030_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	030	0	1	09	04	H2944_030_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	030	0	1	09	04	H2944_030_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	030	0	1	09	04	H2944_030_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	030	0	1	09	04	H2944_030_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	031	0	1	09	04	H2944_031_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	031	0	1	09	04	H2944_031_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	031	0	1	09	04	H2944_031_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	031	0	1	09	04	H2944_031_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	031	0	1	09	04	H2944_031_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	031	0	1	09	04	H2944_031_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	031	0	1	09	04	H2944_031_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	031	0	1	09	04	H2944_031_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	032	0	1	09	04	H2944_032_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	032	0	1	09	04	H2944_032_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	032	0	1	09	04	H2944_032_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	032	0	1	09	04	H2944_032_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	032	0	1	09	04	H2944_032_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	032	0	1	09	04	H2944_032_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	032	0	1	09	04	H2944_032_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	032	0	1	09	04	H2944_032_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	033	0	1	09	04	H2944_033_0	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	033	0	1	09	04	H2944_033_0	10	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	033	0	1	09	04	H2944_033_0	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	033	0	1	09	04	H2944_033_0	10	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	033	0	1	09	04	H2944_033_0	10	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	033	0	1	09	04	H2944_033_0	10	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	033	0	1	09	04	H2944_033_0	10	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	033	0	1	09	04	H2944_033_0	10	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	034	0	1	09	04	H2944_034_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	034	0	1	09	04	H2944_034_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	034	0	1	09	04	H2944_034_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	034	0	1	09	04	H2944_034_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	034	0	1	09	04	H2944_034_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	034	0	1	09	04	H2944_034_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	034	0	1	09	04	H2944_034_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	034	0	1	09	04	H2944_034_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	035	0	1	09	04	H2944_035_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	035	0	1	09	04	H2944_035_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	035	0	1	09	04	H2944_035_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	035	0	1	09	04	H2944_035_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	035	0	1	09	04	H2944_035_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	035	0	1	09	04	H2944_035_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	035	0	1	09	04	H2944_035_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	035	0	1	09	04	H2944_035_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	036	0	1	09	04	H2944_036_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	036	0	1	09	04	H2944_036_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	036	0	1	09	04	H2944_036_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	036	0	1	09	04	H2944_036_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	036	0	1	09	04	H2944_036_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	036	0	1	09	04	H2944_036_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	036	0	1	09	04	H2944_036_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	036	0	1	09	04	H2944_036_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	037	0	1	09	04	H2944_037_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	037	0	1	09	04	H2944_037_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	037	0	1	09	04	H2944_037_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	037	0	1	09	04	H2944_037_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	037	0	1	09	04	H2944_037_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	037	0	1	09	04	H2944_037_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	037	0	1	09	04	H2944_037_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	037	0	1	09	04	H2944_037_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	038	0	1	09	04	H2944_038_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	038	0	1	09	04	H2944_038_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	038	0	1	09	04	H2944_038_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	038	0	1	09	04	H2944_038_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	038	0	1	09	04	H2944_038_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	038	0	1	09	04	H2944_038_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	038	0	1	09	04	H2944_038_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	038	0	1	09	04	H2944_038_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	039	0	1	09	04	H2944_039_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	039	0	1	09	04	H2944_039_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	039	0	1	09	04	H2944_039_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	039	0	1	09	04	H2944_039_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	039	0	1	09	04	H2944_039_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	039	0	1	09	04	H2944_039_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	039	0	1	09	04	H2944_039_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	039	0	1	09	04	H2944_039_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	040	0	1	09	04	H2944_040_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	040	0	1	09	04	H2944_040_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	040	0	1	09	04	H2944_040_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	040	0	1	09	04	H2944_040_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	040	0	1	09	04	H2944_040_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	040	0	1	09	04	H2944_040_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	040	0	1	09	04	H2944_040_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	040	0	1	09	04	H2944_040_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	041	0	1	09	04	H2944_041_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	041	0	1	09	04	H2944_041_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	041	0	1	09	04	H2944_041_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	041	0	1	09	04	H2944_041_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	041	0	1	09	04	H2944_041_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	041	0	1	09	04	H2944_041_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	041	0	1	09	04	H2944_041_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	041	0	1	09	04	H2944_041_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	042	0	1	09	04	H2944_042_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	042	0	1	09	04	H2944_042_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	042	0	1	09	04	H2944_042_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	042	0	1	09	04	H2944_042_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	042	0	1	09	04	H2944_042_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	042	0	1	09	04	H2944_042_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	042	0	1	09	04	H2944_042_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	042	0	1	09	04	H2944_042_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	043	0	1	09	04	H2944_043_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	043	0	1	09	04	H2944_043_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	043	0	1	09	04	H2944_043_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	043	0	1	09	04	H2944_043_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	043	0	1	09	04	H2944_043_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	043	0	1	09	04	H2944_043_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	043	0	1	09	04	H2944_043_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	043	0	1	09	04	H2944_043_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	044	0	1	09	04	H2944_044_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	044	0	1	09	04	H2944_044_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	044	0	1	09	04	H2944_044_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	044	0	1	09	04	H2944_044_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	044	0	1	09	04	H2944_044_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	044	0	1	09	04	H2944_044_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	044	0	1	09	04	H2944_044_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	044	0	1	09	04	H2944_044_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	046	0	1	09	04	H2944_046_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	046	0	1	09	04	H2944_046_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	046	0	1	09	04	H2944_046_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	046	0	1	09	04	H2944_046_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	046	0	1	09	04	H2944_046_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	046	0	1	09	04	H2944_046_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	046	0	1	09	04	H2944_046_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	046	0	1	09	04	H2944_046_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	047	0	1	09	04	H2944_047_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	047	0	1	09	04	H2944_047_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	047	0	1	09	04	H2944_047_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	047	0	1	09	04	H2944_047_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	047	0	1	09	04	H2944_047_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	047	0	1	09	04	H2944_047_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	047	0	1	09	04	H2944_047_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	047	0	1	09	04	H2944_047_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	049	0	1	09	04	H2944_049_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	049	0	1	09	04	H2944_049_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	049	0	1	09	04	H2944_049_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	049	0	1	09	04	H2944_049_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	049	0	1	09	04	H2944_049_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	049	0	1	09	04	H2944_049_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	049	0	1	09	04	H2944_049_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	049	0	1	09	04	H2944_049_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	051	0	1	09	04	H2944_051_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	051	0	1	09	04	H2944_051_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	051	0	1	09	04	H2944_051_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	051	0	1	09	04	H2944_051_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	051	0	1	09	04	H2944_051_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	051	0	1	09	04	H2944_051_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	051	0	1	09	04	H2944_051_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	051	0	1	09	04	H2944_051_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	052	0	1	09	04	H2944_052_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	052	0	1	09	04	H2944_052_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	052	0	1	09	04	H2944_052_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	052	0	1	09	04	H2944_052_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	052	0	1	09	04	H2944_052_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	052	0	1	09	04	H2944_052_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	052	0	1	09	04	H2944_052_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	052	0	1	09	04	H2944_052_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	053	0	1	09	04	H2944_053_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	053	0	1	09	04	H2944_053_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	053	0	1	09	04	H2944_053_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	053	0	1	09	04	H2944_053_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	053	0	1	09	04	H2944_053_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	053	0	1	09	04	H2944_053_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	053	0	1	09	04	H2944_053_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	053	0	1	09	04	H2944_053_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	054	0	1	09	04	H2944_054_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	054	0	1	09	04	H2944_054_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	054	0	1	09	04	H2944_054_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	054	0	1	09	04	H2944_054_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	054	0	1	09	04	H2944_054_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	054	0	1	09	04	H2944_054_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	054	0	1	09	04	H2944_054_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	054	0	1	09	04	H2944_054_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	055	0	1	09	04	H2944_055_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	055	0	1	09	04	H2944_055_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	055	0	1	09	04	H2944_055_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	055	0	1	09	04	H2944_055_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	055	0	1	09	04	H2944_055_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	055	0	1	09	04	H2944_055_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	055	0	1	09	04	H2944_055_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	055	0	1	09	04	H2944_055_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	056	0	1	09	04	H2944_056_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	056	0	1	09	04	H2944_056_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	056	0	1	09	04	H2944_056_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	056	0	1	09	04	H2944_056_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	056	0	1	09	04	H2944_056_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	056	0	1	09	04	H2944_056_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	056	0	1	09	04	H2944_056_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	056	0	1	09	04	H2944_056_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	057	0	1	09	04	H2944_057_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	057	0	1	09	04	H2944_057_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	057	0	1	09	04	H2944_057_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	057	0	1	09	04	H2944_057_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	057	0	1	09	04	H2944_057_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	057	0	1	09	04	H2944_057_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	057	0	1	09	04	H2944_057_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	057	0	1	09	04	H2944_057_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	058	0	1	09	04	H2944_058_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	058	0	1	09	04	H2944_058_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	058	0	1	09	04	H2944_058_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	058	0	1	09	04	H2944_058_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	058	0	1	09	04	H2944_058_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	058	0	1	09	04	H2944_058_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	058	0	1	09	04	H2944_058_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	058	0	1	09	04	H2944_058_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	059	0	1	09	04	H2944_059_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	059	0	1	09	04	H2944_059_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	059	0	1	09	04	H2944_059_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	059	0	1	09	04	H2944_059_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	059	0	1	09	04	H2944_059_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	059	0	1	09	04	H2944_059_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	059	0	1	09	04	H2944_059_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	059	0	1	09	04	H2944_059_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	060	0	1	09	04	H2944_060_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	060	0	1	09	04	H2944_060_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	060	0	1	09	04	H2944_060_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	060	0	1	09	04	H2944_060_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	060	0	1	09	04	H2944_060_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	060	0	1	09	04	H2944_060_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	060	0	1	09	04	H2944_060_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	060	0	1	09	04	H2944_060_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	061	0	1	09	04	H2944_061_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	061	0	1	09	04	H2944_061_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	061	0	1	09	04	H2944_061_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	061	0	1	09	04	H2944_061_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	061	0	1	09	04	H2944_061_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	061	0	1	09	04	H2944_061_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	061	0	1	09	04	H2944_061_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	061	0	1	09	04	H2944_061_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	062	0	1	09	04	H2944_062_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	062	0	1	09	04	H2944_062_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	062	0	1	09	04	H2944_062_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	062	0	1	09	04	H2944_062_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	062	0	1	09	04	H2944_062_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	062	0	1	09	04	H2944_062_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	062	0	1	09	04	H2944_062_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	062	0	1	09	04	H2944_062_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	063	0	1	09	04	H2944_063_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	063	0	1	09	04	H2944_063_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	063	0	1	09	04	H2944_063_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	063	0	1	09	04	H2944_063_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	063	0	1	09	04	H2944_063_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	063	0	1	09	04	H2944_063_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	063	0	1	09	04	H2944_063_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	063	0	1	09	04	H2944_063_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	064	0	1	09	04	H2944_064_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	064	0	1	09	04	H2944_064_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	064	0	1	09	04	H2944_064_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	064	0	1	09	04	H2944_064_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	064	0	1	09	04	H2944_064_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	064	0	1	09	04	H2944_064_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	064	0	1	09	04	H2944_064_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	064	0	1	09	04	H2944_064_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	065	0	1	09	04	H2944_065_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	065	0	1	09	04	H2944_065_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	065	0	1	09	04	H2944_065_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	065	0	1	09	04	H2944_065_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	065	0	1	09	04	H2944_065_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	065	0	1	09	04	H2944_065_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	065	0	1	09	04	H2944_065_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	065	0	1	09	04	H2944_065_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	066	0	1	09	04	H2944_066_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	066	0	1	09	04	H2944_066_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	066	0	1	09	04	H2944_066_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	066	0	1	09	04	H2944_066_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	066	0	1	09	04	H2944_066_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	066	0	1	09	04	H2944_066_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	066	0	1	09	04	H2944_066_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	066	0	1	09	04	H2944_066_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	067	0	1	09	04	H2944_067_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	067	0	1	09	04	H2944_067_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	067	0	1	09	04	H2944_067_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	067	0	1	09	04	H2944_067_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	067	0	1	09	04	H2944_067_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	067	0	1	09	04	H2944_067_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	067	0	1	09	04	H2944_067_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	067	0	1	09	04	H2944_067_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	069	0	1	09	04	H2944_069_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	069	0	1	09	04	H2944_069_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	069	0	1	09	04	H2944_069_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	069	0	1	09	04	H2944_069_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	069	0	1	09	04	H2944_069_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	069	0	1	09	04	H2944_069_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	069	0	1	09	04	H2944_069_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	069	0	1	09	04	H2944_069_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	070	0	1	09	04	H2944_070_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	070	0	1	09	04	H2944_070_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	070	0	1	09	04	H2944_070_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	070	0	1	09	04	H2944_070_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	070	0	1	09	04	H2944_070_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	070	0	1	09	04	H2944_070_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	070	0	1	09	04	H2944_070_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	070	0	1	09	04	H2944_070_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	071	0	1	09	04	H2944_071_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	071	0	1	09	04	H2944_071_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	071	0	1	09	04	H2944_071_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	071	0	1	09	04	H2944_071_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	071	0	1	09	04	H2944_071_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	071	0	1	09	04	H2944_071_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	071	0	1	09	04	H2944_071_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	071	0	1	09	04	H2944_071_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	073	0	1	09	04	H2944_073_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	073	0	1	09	04	H2944_073_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	073	0	1	09	04	H2944_073_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	073	0	1	09	04	H2944_073_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	073	0	1	09	04	H2944_073_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	073	0	1	09	04	H2944_073_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	073	0	1	09	04	H2944_073_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	073	0	1	09	04	H2944_073_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	074	0	1	09	04	H2944_074_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	074	0	1	09	04	H2944_074_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	074	0	1	09	04	H2944_074_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	074	0	1	09	04	H2944_074_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	074	0	1	09	04	H2944_074_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	074	0	1	09	04	H2944_074_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	074	0	1	09	04	H2944_074_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	074	0	1	09	04	H2944_074_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	075	0	1	09	04	H2944_075_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	075	0	1	09	04	H2944_075_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	075	0	1	09	04	H2944_075_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	075	0	1	09	04	H2944_075_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	075	0	1	09	04	H2944_075_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	075	0	1	09	04	H2944_075_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	075	0	1	09	04	H2944_075_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	075	0	1	09	04	H2944_075_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	076	0	1	09	04	H2944_076_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	076	0	1	09	04	H2944_076_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	076	0	1	09	04	H2944_076_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	076	0	1	09	04	H2944_076_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	076	0	1	09	04	H2944_076_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	076	0	1	09	04	H2944_076_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	076	0	1	09	04	H2944_076_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	076	0	1	09	04	H2944_076_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	077	0	1	09	04	H2944_077_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	077	0	1	09	04	H2944_077_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	077	0	1	09	04	H2944_077_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	077	0	1	09	04	H2944_077_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	077	0	1	09	04	H2944_077_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	077	0	1	09	04	H2944_077_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	077	0	1	09	04	H2944_077_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	077	0	1	09	04	H2944_077_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	078	0	1	09	04	H2944_078_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	078	0	1	09	04	H2944_078_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	078	0	1	09	04	H2944_078_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	078	0	1	09	04	H2944_078_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	078	0	1	09	04	H2944_078_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	078	0	1	09	04	H2944_078_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	078	0	1	09	04	H2944_078_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	078	0	1	09	04	H2944_078_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	079	0	1	09	04	H2944_079_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	079	0	1	09	04	H2944_079_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	079	0	1	09	04	H2944_079_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	079	0	1	09	04	H2944_079_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	079	0	1	09	04	H2944_079_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	079	0	1	09	04	H2944_079_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	079	0	1	09	04	H2944_079_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	079	0	1	09	04	H2944_079_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	080	0	1	09	04	H2944_080_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	080	0	1	09	04	H2944_080_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	080	0	1	09	04	H2944_080_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	080	0	1	09	04	H2944_080_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	080	0	1	09	04	H2944_080_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	080	0	1	09	04	H2944_080_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	080	0	1	09	04	H2944_080_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	080	0	1	09	04	H2944_080_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	081	0	1	09	04	H2944_081_0	10	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	081	0	1	09	04	H2944_081_0	10	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	081	0	1	09	04	H2944_081_0	10	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	081	0	1	09	04	H2944_081_0	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	081	0	1	09	04	H2944_081_0	10	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	081	0	1	09	04	H2944_081_0	10	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	081	0	1	09	04	H2944_081_0	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	081	0	1	09	04	H2944_081_0	10	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	082	0	1	09	04	H2944_082_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	082	0	1	09	04	H2944_082_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	082	0	1	09	04	H2944_082_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	082	0	1	09	04	H2944_082_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	082	0	1	09	04	H2944_082_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	082	0	1	09	04	H2944_082_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	082	0	1	09	04	H2944_082_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	082	0	1	09	04	H2944_082_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	084	0	1	09	04	H2944_084_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	084	0	1	09	04	H2944_084_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	084	0	1	09	04	H2944_084_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	084	0	1	09	04	H2944_084_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	084	0	1	09	04	H2944_084_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	084	0	1	09	04	H2944_084_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	084	0	1	09	04	H2944_084_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	084	0	1	09	04	H2944_084_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	085	0	1	09	04	H2944_085_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	085	0	1	09	04	H2944_085_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	085	0	1	09	04	H2944_085_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	085	0	1	09	04	H2944_085_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	085	0	1	09	04	H2944_085_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	085	0	1	09	04	H2944_085_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	085	0	1	09	04	H2944_085_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	085	0	1	09	04	H2944_085_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	086	0	1	09	04	H2944_086_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	086	0	1	09	04	H2944_086_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	086	0	1	09	04	H2944_086_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	086	0	1	09	04	H2944_086_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	086	0	1	09	04	H2944_086_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	086	0	1	09	04	H2944_086_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	086	0	1	09	04	H2944_086_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	086	0	1	09	04	H2944_086_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	087	0	1	09	04	H2944_087_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	087	0	1	09	04	H2944_087_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	087	0	1	09	04	H2944_087_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	087	0	1	09	04	H2944_087_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	087	0	1	09	04	H2944_087_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	087	0	1	09	04	H2944_087_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	087	0	1	09	04	H2944_087_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	087	0	1	09	04	H2944_087_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	088	0	1	09	04	H2944_088_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	088	0	1	09	04	H2944_088_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	088	0	1	09	04	H2944_088_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2944	088	0	1	09	04	H2944_088_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	088	0	1	09	04	H2944_088_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	088	0	1	09	04	H2944_088_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	088	0	1	09	04	H2944_088_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	088	0	1	09	04	H2944_088_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2944	089	0	1	09	04	H2944_089_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H2944	089	0	1	09	04	H2944_089_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	089	0	1	09	04	H2944_089_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	089	0	1	09	04	H2944_089_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	089	0	1	09	04	H2944_089_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H2944	089	0	1	09	04	H2944_089_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	089	0	1	09	04	H2944_089_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	089	0	1	09	04	H2944_089_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	090	0	1	09	04	H2944_090_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	090	0	1	09	04	H2944_090_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	090	0	1	09	04	H2944_090_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	090	0	1	09	04	H2944_090_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	090	0	1	09	04	H2944_090_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	090	0	1	09	04	H2944_090_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	090	0	1	09	04	H2944_090_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	090	0	1	09	04	H2944_090_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	091	0	1	09	04	H2944_091_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	091	0	1	09	04	H2944_091_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	091	0	1	09	04	H2944_091_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	091	0	1	09	04	H2944_091_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	091	0	1	09	04	H2944_091_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	091	0	1	09	04	H2944_091_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	091	0	1	09	04	H2944_091_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	091	0	1	09	04	H2944_091_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	092	0	1	09	04	H2944_092_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	092	0	1	09	04	H2944_092_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	092	0	1	09	04	H2944_092_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	092	0	1	09	04	H2944_092_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	092	0	1	09	04	H2944_092_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	092	0	1	09	04	H2944_092_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	092	0	1	09	04	H2944_092_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	092	0	1	09	04	H2944_092_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	093	0	1	09	04	H2944_093_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	093	0	1	09	04	H2944_093_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	093	0	1	09	04	H2944_093_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	093	0	1	09	04	H2944_093_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	093	0	1	09	04	H2944_093_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	093	0	1	09	04	H2944_093_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	093	0	1	09	04	H2944_093_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	093	0	1	09	04	H2944_093_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	094	0	1	09	04	H2944_094_0	7	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	094	0	1	09	04	H2944_094_0	7	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	094	0	1	09	04	H2944_094_0	7	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H2944	094	0	1	09	04	H2944_094_0	7	4	3	1	Specialty	110110		1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	095	0	1	09	04	H2944_095_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	095	0	1	09	04	H2944_095_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	095	0	1	09	04	H2944_095_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	095	0	1	09	04	H2944_095_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	095	0	1	09	04	H2944_095_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	095	0	1	09	04	H2944_095_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	095	0	1	09	04	H2944_095_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	095	0	1	09	04	H2944_095_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	096	0	1	09	04	H2944_096_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H2944	096	0	1	09	04	H2944_096_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	096	0	1	09	04	H2944_096_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	096	0	1	09	04	H2944_096_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	096	0	1	09	04	H2944_096_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H2944	096	0	1	09	04	H2944_096_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	096	0	1	09	04	H2944_096_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	096	0	1	09	04	H2944_096_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	097	0	1	09	04	H2944_097_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	097	0	1	09	04	H2944_097_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	097	0	1	09	04	H2944_097_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	097	0	1	09	04	H2944_097_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	097	0	1	09	04	H2944_097_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	097	0	1	09	04	H2944_097_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	097	0	1	09	04	H2944_097_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	097	0	1	09	04	H2944_097_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	098	0	1	09	04	H2944_098_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	098	0	1	09	04	H2944_098_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	098	0	1	09	04	H2944_098_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	098	0	1	09	04	H2944_098_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	098	0	1	09	04	H2944_098_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	098	0	1	09	04	H2944_098_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	098	0	1	09	04	H2944_098_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	098	0	1	09	04	H2944_098_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	099	0	1	09	04	H2944_099_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	099	0	1	09	04	H2944_099_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	099	0	1	09	04	H2944_099_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	099	0	1	09	04	H2944_099_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	099	0	1	09	04	H2944_099_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	099	0	1	09	04	H2944_099_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	099	0	1	09	04	H2944_099_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	099	0	1	09	04	H2944_099_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	100	0	1	09	04	H2944_100_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	100	0	1	09	04	H2944_100_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H2944	100	0	1	09	04	H2944_100_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	100	0	1	09	04	H2944_100_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H2944	100	0	1	09	04	H2944_100_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	100	0	1	09	04	H2944_100_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	100	0	1	09	04	H2944_100_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	100	0	1	09	04	H2944_100_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	101	0	1	09	04	H2944_101_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	101	0	1	09	04	H2944_101_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	101	0	1	09	04	H2944_101_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	101	0	1	09	04	H2944_101_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	101	0	1	09	04	H2944_101_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	101	0	1	09	04	H2944_101_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	101	0	1	09	04	H2944_101_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	101	0	1	09	04	H2944_101_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	107	0	1	09	04	H2944_107_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	107	0	1	09	04	H2944_107_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	107	0	1	09	04	H2944_107_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	107	0	1	09	04	H2944_107_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	107	0	1	09	04	H2944_107_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	107	0	1	09	04	H2944_107_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	107	0	1	09	04	H2944_107_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	107	0	1	09	04	H2944_107_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	108	0	1	09	04	H2944_108_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	108	0	1	09	04	H2944_108_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	108	0	1	09	04	H2944_108_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	108	0	1	09	04	H2944_108_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	108	0	1	09	04	H2944_108_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	108	0	1	09	04	H2944_108_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	108	0	1	09	04	H2944_108_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	108	0	1	09	04	H2944_108_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	109	0	1	09	04	H2944_109_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	109	0	1	09	04	H2944_109_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	109	0	1	09	04	H2944_109_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	109	0	1	09	04	H2944_109_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	109	0	1	09	04	H2944_109_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	109	0	1	09	04	H2944_109_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	109	0	1	09	04	H2944_109_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	109	0	1	09	04	H2944_109_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	110	0	1	09	04	H2944_110_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	110	0	1	09	04	H2944_110_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	110	0	1	09	04	H2944_110_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	110	0	1	09	04	H2944_110_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	110	0	1	09	04	H2944_110_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	110	0	1	09	04	H2944_110_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	110	0	1	09	04	H2944_110_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	110	0	1	09	04	H2944_110_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	111	0	1	09	04	H2944_111_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	111	0	1	09	04	H2944_111_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	111	0	1	09	04	H2944_111_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	111	0	1	09	04	H2944_111_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	111	0	1	09	04	H2944_111_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	111	0	1	09	04	H2944_111_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	111	0	1	09	04	H2944_111_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	111	0	1	09	04	H2944_111_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	112	0	1	09	04	H2944_112_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	112	0	1	09	04	H2944_112_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	112	0	1	09	04	H2944_112_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	112	0	1	09	04	H2944_112_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	112	0	1	09	04	H2944_112_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	112	0	1	09	04	H2944_112_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	112	0	1	09	04	H2944_112_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	112	0	1	09	04	H2944_112_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	113	0	1	09	04	H2944_113_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	113	0	1	09	04	H2944_113_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	113	0	1	09	04	H2944_113_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	113	0	1	09	04	H2944_113_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	113	0	1	09	04	H2944_113_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	113	0	1	09	04	H2944_113_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	113	0	1	09	04	H2944_113_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	113	0	1	09	04	H2944_113_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	114	0	1	09	04	H2944_114_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	114	0	1	09	04	H2944_114_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	114	0	1	09	04	H2944_114_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	114	0	1	09	04	H2944_114_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	114	0	1	09	04	H2944_114_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	114	0	1	09	04	H2944_114_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	114	0	1	09	04	H2944_114_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	114	0	1	09	04	H2944_114_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	115	0	1	09	04	H2944_115_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	115	0	1	09	04	H2944_115_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	115	0	1	09	04	H2944_115_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	115	0	1	09	04	H2944_115_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	115	0	1	09	04	H2944_115_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	115	0	1	09	04	H2944_115_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	115	0	1	09	04	H2944_115_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	115	0	1	09	04	H2944_115_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non_Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non_Preferred Brand	2	Non_Preferred Brand																						Non_Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	116	0	1	09	04	H2944_116_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	116	0	1	09	04	H2944_116_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	116	0	1	09	04	H2944_116_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	116	0	1	09	04	H2944_116_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	116	0	1	09	04	H2944_116_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	116	0	1	09	04	H2944_116_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	116	0	1	09	04	H2944_116_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	116	0	1	09	04	H2944_116_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	117	0	1	09	04	H2944_117_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	117	0	1	09	04	H2944_117_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	117	0	1	09	04	H2944_117_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	117	0	1	09	04	H2944_117_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	117	0	1	09	04	H2944_117_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	117	0	1	09	04	H2944_117_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	117	0	1	09	04	H2944_117_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	117	0	1	09	04	H2944_117_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	118	0	1	09	04	H2944_118_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	118	0	1	09	04	H2944_118_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	118	0	1	09	04	H2944_118_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	118	0	1	09	04	H2944_118_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	118	0	1	09	04	H2944_118_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	118	0	1	09	04	H2944_118_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	118	0	1	09	04	H2944_118_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	118	0	1	09	04	H2944_118_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	119	0	1	09	04	H2944_119_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	119	0	1	09	04	H2944_119_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	119	0	1	09	04	H2944_119_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	119	0	1	09	04	H2944_119_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	119	0	1	09	04	H2944_119_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	119	0	1	09	04	H2944_119_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	119	0	1	09	04	H2944_119_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	119	0	1	09	04	H2944_119_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	120	0	1	09	04	H2944_120_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	120	0	1	09	04	H2944_120_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	120	0	1	09	04	H2944_120_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	120	0	1	09	04	H2944_120_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	120	0	1	09	04	H2944_120_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	120	0	1	09	04	H2944_120_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	120	0	1	09	04	H2944_120_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	120	0	1	09	04	H2944_120_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	121	0	1	09	04	H2944_121_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	121	0	1	09	04	H2944_121_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	121	0	1	09	04	H2944_121_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	121	0	1	09	04	H2944_121_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	121	0	1	09	04	H2944_121_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	121	0	1	09	04	H2944_121_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	121	0	1	09	04	H2944_121_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	121	0	1	09	04	H2944_121_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	122	0	1	09	04	H2944_122_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	122	0	1	09	04	H2944_122_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	122	0	1	09	04	H2944_122_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	122	0	1	09	04	H2944_122_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	122	0	1	09	04	H2944_122_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	122	0	1	09	04	H2944_122_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	122	0	1	09	04	H2944_122_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	122	0	1	09	04	H2944_122_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	123	0	1	09	04	H2944_123_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H2944	123	0	1	09	04	H2944_123_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	123	0	1	09	04	H2944_123_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	123	0	1	09	04	H2944_123_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	123	0	1	09	04	H2944_123_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H2944	123	0	1	09	04	H2944_123_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	123	0	1	09	04	H2944_123_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	123	0	1	09	04	H2944_123_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	124	0	1	09	04	H2944_124_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	124	0	1	09	04	H2944_124_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	124	0	1	09	04	H2944_124_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	124	0	1	09	04	H2944_124_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	124	0	1	09	04	H2944_124_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	124	0	1	09	04	H2944_124_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	124	0	1	09	04	H2944_124_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	124	0	1	09	04	H2944_124_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	125	0	1	09	04	H2944_125_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	125	0	1	09	04	H2944_125_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	125	0	1	09	04	H2944_125_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	125	0	1	09	04	H2944_125_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H2944	125	0	1	09	04	H2944_125_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	125	0	1	09	04	H2944_125_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	125	0	1	09	04	H2944_125_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	125	0	1	09	04	H2944_125_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2944	127	0	1	09	04	H2944_127_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	127	0	1	09	04	H2944_127_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	127	0	1	09	04	H2944_127_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	127	0	1	09	04	H2944_127_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	127	0	1	09	04	H2944_127_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	127	0	1	09	04	H2944_127_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	127	0	1	09	04	H2944_127_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	127	0	1	09	04	H2944_127_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	128	0	1	09	04	H2944_128_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	128	0	1	09	04	H2944_128_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	128	0	1	09	04	H2944_128_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	128	0	1	09	04	H2944_128_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	128	0	1	09	04	H2944_128_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	128	0	1	09	04	H2944_128_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	128	0	1	09	04	H2944_128_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	128	0	1	09	04	H2944_128_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	129	0	1	09	04	H2944_129_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	129	0	1	09	04	H2944_129_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	129	0	1	09	04	H2944_129_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	129	0	1	09	04	H2944_129_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00	1	2	10001000
H2944	129	0	1	09	04	H2944_129_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	129	0	1	09	04	H2944_129_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	129	0	1	09	04	H2944_129_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	129	0	1	09	04	H2944_129_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00			
H2944	131	0	1	09	04	H2944_131_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	131	0	1	09	04	H2944_131_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	131	0	1	09	04	H2944_131_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	131	0	1	09	04	H2944_131_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	131	0	1	09	04	H2944_131_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	131	0	1	09	04	H2944_131_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	131	0	1	09	04	H2944_131_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	131	0	1	09	04	H2944_131_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	132	0	1	09	04	H2944_132_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	132	0	1	09	04	H2944_132_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	132	0	1	09	04	H2944_132_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	132	0	1	09	04	H2944_132_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	132	0	1	09	04	H2944_132_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	132	0	1	09	04	H2944_132_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	132	0	1	09	04	H2944_132_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	132	0	1	09	04	H2944_132_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	133	0	1	09	04	H2944_133_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	133	0	1	09	04	H2944_133_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	133	0	1	09	04	H2944_133_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	133	0	1	09	04	H2944_133_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	133	0	1	09	04	H2944_133_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	133	0	1	09	04	H2944_133_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	133	0	1	09	04	H2944_133_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	133	0	1	09	04	H2944_133_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	134	0	1	09	04	H2944_134_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	134	0	1	09	04	H2944_134_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	134	0	1	09	04	H2944_134_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	134	0	1	09	04	H2944_134_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	134	0	1	09	04	H2944_134_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	134	0	1	09	04	H2944_134_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	134	0	1	09	04	H2944_134_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	134	0	1	09	04	H2944_134_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	135	0	1	09	04	H2944_135_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	135	0	1	09	04	H2944_135_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	135	0	1	09	04	H2944_135_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	135	0	1	09	04	H2944_135_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	135	0	1	09	04	H2944_135_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	135	0	1	09	04	H2944_135_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	135	0	1	09	04	H2944_135_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	135	0	1	09	04	H2944_135_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	136	0	1	09	04	H2944_136_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	136	0	1	09	04	H2944_136_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	136	0	1	09	04	H2944_136_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	136	0	1	09	04	H2944_136_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	136	0	1	09	04	H2944_136_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	136	0	1	09	04	H2944_136_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	136	0	1	09	04	H2944_136_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	136	0	1	09	04	H2944_136_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	137	0	1	09	04	H2944_137_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	137	0	1	09	04	H2944_137_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	137	0	1	09	04	H2944_137_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	137	0	1	09	04	H2944_137_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	137	0	1	09	04	H2944_137_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	137	0	1	09	04	H2944_137_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	137	0	1	09	04	H2944_137_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	137	0	1	09	04	H2944_137_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	138	0	1	09	04	H2944_138_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	138	0	1	09	04	H2944_138_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	138	0	1	09	04	H2944_138_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	138	0	1	09	04	H2944_138_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	138	0	1	09	04	H2944_138_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	138	0	1	09	04	H2944_138_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	138	0	1	09	04	H2944_138_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	138	0	1	09	04	H2944_138_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	139	0	1	09	04	H2944_139_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H2944	139	0	1	09	04	H2944_139_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	139	0	1	09	04	H2944_139_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	139	0	1	09	04	H2944_139_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	139	0	1	09	04	H2944_139_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	139	0	1	09	04	H2944_139_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	139	0	1	09	04	H2944_139_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	139	0	1	09	04	H2944_139_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H2944	140	0	1	09	04	H2944_140_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	140	0	1	09	04	H2944_140_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	140	0	1	09	04	H2944_140_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	140	0	1	09	04	H2944_140_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	140	0	1	09	04	H2944_140_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	140	0	1	09	04	H2944_140_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	140	0	1	09	04	H2944_140_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	140	0	1	09	04	H2944_140_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	141	0	1	09	04	H2944_141_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	141	0	1	09	04	H2944_141_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00	1	2	10001000
H2944	141	0	1	09	04	H2944_141_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H2944	141	0	1	09	04	H2944_141_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	141	0	1	09	04	H2944_141_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	141	0	1	09	04	H2944_141_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	38.00	114.00								38.00					38.00	95.00		38.00	114.00		38.00			
H2944	141	0	1	09	04	H2944_141_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H2944	141	0	1	09	04	H2944_141_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	142	0	1	09	04	H2944_142_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00	1	2	10000000
H2944	142	0	1	09	04	H2944_142_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	142	0	1	09	04	H2944_142_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	142	0	1	09	04	H2944_142_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	142	0	1	09	04	H2944_142_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H2944	142	0	1	09	04	H2944_142_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	142	0	1	09	04	H2944_142_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	142	0	1	09	04	H2944_142_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	143	0	1	09	04	H2944_143_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	143	0	1	09	04	H2944_143_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	143	0	1	09	04	H2944_143_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	143	0	1	09	04	H2944_143_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H2944	143	0	1	09	04	H2944_143_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	143	0	1	09	04	H2944_143_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	143	0	1	09	04	H2944_143_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	143	0	1	09	04	H2944_143_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00	1	2	10000000
H2944	144	0	1	09	04	H2944_144_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	144	0	1	09	04	H2944_144_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H2944	144	0	1	09	04	H2944_144_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	144	0	1	09	04	H2944_144_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H2944	144	0	1	09	04	H2944_144_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	144	0	1	09	04	H2944_144_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H2944	144	0	1	09	04	H2944_144_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	144	0	1	09	04	H2944_144_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00	1	2	10000000
H2944	146	0	1	09	04	H2944_146_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	146	0	1	09	04	H2944_146_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	146	0	1	09	04	H2944_146_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	146	0	1	09	04	H2944_146_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	146	0	1	09	04	H2944_146_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	146	0	1	09	04	H2944_146_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	146	0	1	09	04	H2944_146_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	146	0	1	09	04	H2944_146_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	147	0	1	09	04	H2944_147_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	147	0	1	09	04	H2944_147_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	147	0	1	09	04	H2944_147_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	147	0	1	09	04	H2944_147_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	147	0	1	09	04	H2944_147_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	147	0	1	09	04	H2944_147_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	147	0	1	09	04	H2944_147_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	147	0	1	09	04	H2944_147_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	148	0	1	09	04	H2944_148_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	148	0	1	09	04	H2944_148_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	148	0	1	09	04	H2944_148_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	148	0	1	09	04	H2944_148_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	148	0	1	09	04	H2944_148_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	148	0	1	09	04	H2944_148_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	148	0	1	09	04	H2944_148_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	148	0	1	09	04	H2944_148_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	149	0	1	09	04	H2944_149_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	149	0	1	09	04	H2944_149_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	149	0	1	09	04	H2944_149_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	149	0	1	09	04	H2944_149_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	149	0	1	09	04	H2944_149_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	149	0	1	09	04	H2944_149_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	149	0	1	09	04	H2944_149_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	149	0	1	09	04	H2944_149_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	150	0	1	09	04	H2944_150_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	150	0	1	09	04	H2944_150_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	150	0	1	09	04	H2944_150_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	150	0	1	09	04	H2944_150_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	150	0	1	09	04	H2944_150_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	150	0	1	09	04	H2944_150_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	150	0	1	09	04	H2944_150_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	150	0	1	09	04	H2944_150_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	151	0	1	09	04	H2944_151_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	151	0	1	09	04	H2944_151_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2944	151	0	1	09	04	H2944_151_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	151	0	1	09	04	H2944_151_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	151	0	1	09	04	H2944_151_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	151	0	1	09	04	H2944_151_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	151	0	1	09	04	H2944_151_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	151	0	1	09	04	H2944_151_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	152	0	1	09	04	H2944_152_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H2944	152	0	1	09	04	H2944_152_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H2944	152	0	1	09	04	H2944_152_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H2944	152	0	1	09	04	H2944_152_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H2944	152	0	1	09	04	H2944_152_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2944	152	0	1	09	04	H2944_152_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2944	152	0	1	09	04	H2944_152_0	2	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2944	152	0	1	09	04	H2944_152_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2949	002	0	1	01	01	H2949_002_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2949	002	0	1	01	01	H2949_002_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2949	002	0	1	01	01	H2949_002_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00	1	2	10001000
H2949	002	0	1	01	01	H2949_002_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	1	
H2949	002	0	1	01	01	H2949_002_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2949	002	0	1	01	01	H2949_002_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2949	002	0	1	01	01	H2949_002_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00			
H2949	002	0	1	01	01	H2949_002_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2949	007	0	1	01	01	H2949_007_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2949	007	0	1	01	01	H2949_007_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2949	007	0	1	01	01	H2949_007_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2949	007	0	1	01	01	H2949_007_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	1	
H2949	007	0	1	01	01	H2949_007_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2949	007	0	1	01	01	H2949_007_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2949	007	0	1	01	01	H2949_007_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2949	007	0	1	01	01	H2949_007_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2949	012	0	1	01	01	H2949_012_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H2949	012	0	1	01	01	H2949_012_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H2949	012	0	1	01	01	H2949_012_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H2949	012	0	1	01	01	H2949_012_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H2949	012	0	1	01	01	H2949_012_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	1	
H2949	012	0	1	01	01	H2949_012_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H2949	012	0	1	01	01	H2949_012_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H2949	012	0	1	01	01	H2949_012_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H2960	004	0	1	01	01	H2960_004_0	6	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.00	7.50								3.00			7.50								3.00			
H2960	004	0	1	01	01	H2960_004_0	6	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	8.00	20.00								8.00			20.00								8.00			
H2960	004	0	1	01	01	H2960_004_0	6	5	4	3	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical																								Special Pharmaceutical		Special Pharmaceutical																						Special Pharmaceutical																						2		
H2960	004	0	1	01	01	H2960_004_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2960	004	0	1	01	01	H2960_004_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H2960	004	0	1	01	01	H2960_004_0	6	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	8.00	20.00								8.00			20.00								8.00	1	1	
H2960	004	0	1	01	01	H2960_004_0	6	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.00	7.50								3.00			7.50								3.00	1	1	
H2960	004	0	1	01	01	H2960_004_0	6	5	4	1	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical	111000000010010000000	30	90								30			90								31	1	Special Pharmaceutical	1	Special Pharmaceutical	33	33								33			33								33	Special Pharmaceutical																								
H2960	004	0	1	01	01	H2960_004_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	100.00								40.00			100.00								40.00			
H2960	010	0	1	01	01	H2960_010_0	6	5	4	3	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical																								Special Pharmaceutical		Special Pharmaceutical																						Special Pharmaceutical																						2		
H2960	010	0	1	01	01	H2960_010_0	6	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00			
H2960	010	0	1	01	01	H2960_010_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00			87.50								35.00			
H2960	010	0	1	01	01	H2960_010_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	6	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00			
H2960	010	0	1	01	01	H2960_010_0	6	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.00	5.00								2.00			5.00								2.00	1	1	
H2960	010	0	1	01	01	H2960_010_0	6	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	6.00	15.00								6.00			15.00								6.00	1	1	
H2960	010	0	1	01	01	H2960_010_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00			87.50								35.00	1	1	
H2960	010	0	1	01	01	H2960_010_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H2960	010	0	1	01	01	H2960_010_0	6	5	4	1	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical	111000000010010000000	30	90								30			90								31	1	Special Pharmaceutical	1	Special Pharmaceutical	33	33								33			33								33	Special Pharmaceutical																								
H2960	012	0	1	01	01	H2960_012_0	7	5	4	1	Special Pharmaceutical	010010	1	1	2	Special Pharmaceutical	111000000010010000000	30	90								30			90								31	1	Special Pharmaceutical	1	Special Pharmaceutical	33	33								33			33								33	Special Pharmaceutical																								
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																						2		
H2960	012	0	1	01	01	H2960_012_0	7	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
H2960	012	0	1	01	01	H2960_012_0	7	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic																								Non-Preferred Generic		Non-Preferred Generic																						Non-Preferred Generic																						2		
H2960	012	0	1	01	01	H2960_012_0	7	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	10.00								4.00			10.00								4.00	1	1	
H2960	012	0	1	01	01	H2960_012_0	7	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	187.50								75.00			187.50								75.00			
H2960	012	0	1	01	01	H2960_012_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	112.50								45.00			112.50								45.00			
H2960	012	0	1	01	01	H2960_012_0	7	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	10.00	25.00								10.00			25.00								10.00			
H2960	012	0	1	01	01	H2960_012_0	7	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	10.00								4.00			10.00								4.00			
H2961	002	0	1	02	01	H2961_002_0	13	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00			
H2961	002	0	1	02	01	H2961_002_0	13	6	4	3	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand																								Special Coverage - Brand		Special Coverage - Brand																						Special Coverage - Brand																						2		
H2961	002	0	1	02	01	H2961_002_0	13	5	4	3	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00	1	1	
H2961	002	0	1	02	01	H2961_002_0	13	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H2961	002	0	1	02	01	H2961_002_0	13	3	4	1	Non-preferred	100100	1	2	1	Non-preferred	110000000010000000000	30									30											31		Non-preferred	2	Non-preferred																						Non-preferred	85.00									85.00											85.00			
H2961	002	0	1	02	01	H2961_002_0	13	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2961	002	0	1	02	01	H2961_002_0	13	5	4	1	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00			
H2961	002	0	1	02	01	H2961_002_0	13	6	4	1	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand	110000000010000000000	30									30											31		Special Coverage - Brand	2	Special Coverage - Brand																						Special Coverage - Brand	35.00									35.00											35.00			
H2961	002	0	1	02	01	H2961_002_0	13	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00	1	1	
H2961	002	0	1	02	01	H2961_002_0	13	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00	1	1	
H2961	002	0	1	02	01	H2961_002_0	13	3	4	3	Non-preferred	100100	1	2	1	Non-preferred																								Non-preferred		Non-preferred																						Non-preferred																						2		
H2961	002	0	1	02	01	H2961_002_0	13	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2961	011	0	1	02	01	H2961_011_0	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00	1	1	
H2961	011	0	1	02	01	H2961_011_0	10	3	4	3	Non-preferred	100100	1	2	1	Non-preferred																								Non-preferred		Non-preferred																						Non-preferred																						2		
H2961	011	0	1	02	01	H2961_011_0	10	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H2961	011	0	1	02	01	H2961_011_0	10	5	4	3	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00	1	1	
H2961	011	0	1	02	01	H2961_011_0	10	5	4	1	Special Coverage - Generic	010000	2	2	2	Special Coverage - Generic	110000000010000000000	30									30											31		Special Coverage - Generic	2	Special Coverage - Generic																						Special Coverage - Generic	6.00									6.00											6.00			
H2961	011	0	1	02	01	H2961_011_0	10	3	4	1	Non-preferred	100100	1	2	1	Non-preferred	110000000010000000000	30									30											31		Non-preferred	2	Non-preferred																						Non-preferred	85.00									85.00											85.00			
H2961	011	0	1	02	01	H2961_011_0	10	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00			
H2961	011	0	1	02	01	H2961_011_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H2961	011	0	1	02	01	H2961_011_0	10	1	4	3	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00	1	1	
H2961	011	0	1	02	01	H2961_011_0	10	6	4	1	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand	110000000010000000000	30									30											31		Special Coverage - Brand	2	Special Coverage - Brand																						Special Coverage - Brand	35.00									35.00											35.00			
H2961	011	0	1	02	01	H2961_011_0	10	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H2961	011	0	1	02	01	H2961_011_0	10	6	4	3	Special Coverage - Brand	000010	2	2	2	Special Coverage - Brand																								Special Coverage - Brand		Special Coverage - Brand																						Special Coverage - Brand																						2		
H2997	001	0	1	04	01	H2997_001_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H2997	001	0	1	04	01	H2997_001_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H2997	001	0	1	04	01	H2997_001_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H2997	001	0	1	04	01	H2997_001_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H2997	001	0	1	04	01	H2997_001_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H2997	001	0	1	04	01	H2997_001_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H2997	001	0	1	04	01	H2997_001_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H2997	001	0	1	04	01	H2997_001_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H2997	001	0	1	04	01	H2997_001_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H2997	001	0	1	04	01	H2997_001_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H2997	002	0	1	04	01	H2997_002_0	16	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H2997	002	0	1	04	01	H2997_002_0	16	4	4	3	Non-Specialty Injectable Drugs	010010	1	2	2	Non-Specialty Injectable Drugs																								Non-Specialty Injectable Drugs		Non-Specialty Injectable Drugs																						Non-Specialty Injectable Drugs																						2		
H2997	002	0	1	04	01	H2997_002_0	16	3	4	3	Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Non-Preferred Brand  Certain Generic Drugs																								Non-Preferred Brand  Certain Generic Drugs		Non-Preferred Brand  Certain Generic Drugs																						Non-Preferred Brand  Certain Generic Drugs																						2		
H2997	002	0	1	04	01	H2997_002_0	16	2	4	3	Preferred Brand  Certain Generic Drugs	010001	1	2	2	Preferred Brand  Certain Generic Drugs																								Preferred Brand  Certain Generic Drugs		Preferred Brand  Certain Generic Drugs																						Preferred Brand  Certain Generic Drugs																						2		
H2997	002	0	1	04	01	H2997_002_0	16	1	4	3	Preferred Generic Drugs	001000	3	2	2	Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H2997	002	0	1	04	01	H2997_002_0	16	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000100100	30									30					30			30			34		Specialty Drugs	1	Specialty Drugs	33									33					33			33			33	Specialty Drugs																								
H2997	002	0	1	04	01	H2997_002_0	16	4	4	1	Non-Specialty Injectable Drugs	010010	1	2	2	Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Non-Specialty Injectable Drugs	1	Non-Specialty Injectable Drugs	33	33								33						33			33		33	Non-Specialty Injectable Drugs																								
H2997	002	0	1	04	01	H2997_002_0	16	3	4	1	Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Non-Preferred Brand  Certain Generic Drugs	2	Non-Preferred Brand  Certain Generic Drugs																						Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H2997	002	0	1	04	01	H2997_002_0	16	1	4	1	Preferred Generic Drugs	001000	3	2	2	Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H2997	002	0	1	04	01	H2997_002_0	16	2	4	1	Preferred Brand  Certain Generic Drugs	010001	1	2	2	Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Preferred Brand  Certain Generic Drugs	2	Preferred Brand  Certain Generic Drugs																						Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H3028	001	0	1	01	01	H3028_001_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	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	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3028	001	0	1	01	01	H3028_001_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00					50.00	125.00		50.00	150.00		50.00	1	2	10000000
H3028	001	0	1	01	01	H3028_001_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00	1	2	10001000
H3028	001	0	1	01	01	H3028_001_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H3028	001	0	1	01	01	H3028_001_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3028	001	0	1	01	01	H3028_001_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H3044	001	0	1	01	01	H3044_001_0	4	2	4	1	Tier Two	000011	1	2	1	Tier Two	111000000010010000000	30	90								30			90								31	1	Tier Two	2	Tier Two																						Tier Two	39.00	117.00								39.00			78.00								39.00			
H3044	001	0	1	01	01	H3044_001_0	4	4	4	1	Tier 4 Specialty	100001	1	1	2	Tier 4 Specialty	111000000010010000000	30	90								30			90								31	1	Tier 4 Specialty	1	Tier 4 Specialty	30	30								30			30								30	Tier 4 Specialty																								
H3044	001	0	1	01	01	H3044_001_0	4	3	4	1	Tier 3	100001	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00								78.00			156.00								78.00			
H3044	001	0	1	01	01	H3044_001_0	4	1	4	1	Tier One	011100	1	2	2	Tier One	111000000010010000000	30	90								30			90								31	1	Tier One	2	Tier One																						Tier One	8.00	24.00								8.00			8.00								8.00			
H3044	003	0	1	01	01	H3044_003_0	5	3	4	3	Tier Three	100000	1	2	2	Tier Three																								Tier Three		Tier Three																						Tier Three																						2		
H3044	003	0	1	01	01	H3044_003_0	5	4	4	3	Tier Four - Specialty	100001	1	1	2																																																																							2		
H3044	003	0	1	01	01	H3044_003_0	5	4	4	1	Tier Four - Specialty	100001	1	1	2	Tier Four - Specialty	111000000010010000000	30	90								30			90								31	1	Tier Four - Specialty	1	Tier Four - Specialty	25	25								25			25								25	Tier Four - Specialty																								
H3044	003	0	1	01	01	H3044_003_0	5	3	4	1	Tier Three	100000	1	2	2	Tier Three	111000000010010000000	30	90								30			90								31	1	Tier Three	2	Tier Three																						Tier Three	60.00	180.00								60.00			120.00								60.00			
H3044	003	0	1	01	01	H3044_003_0	5	1	4	1	Tier One	011100	1	2	2	Tier One	111000000010010000000	30	90								30			90								31	1	Tier One	2	Tier One																						Tier One	4.00	12.00								4.00			4.00								4.00			
H3044	003	0	1	01	01	H3044_003_0	5	2	4	1	Tier Two	000011	1	2	1	Tier Two	111000000010010000000	30	90								30			90								31	1	Tier Two	2	Tier Two																						Tier Two	30.00	90.00								30.00			60.00								30.00			
H3044	003	0	1	01	01	H3044_003_0	5	2	4	3	Tier Two	000011	1	2	1	Tier Two																								Tier Two		Tier Two																						Tier Two																						2		
H3044	003	0	1	01	01	H3044_003_0	5	1	4	3	Tier One	011100	1	2	2	Tier One	111000000010010000000	30	90								30			90								31	1	Tier One	2	Tier One																						Tier One	4.00	12.00								4.00			4.00								4.00	1	1	
H3044	004	0	1	02	01	H3044_004_0	4	3	4	1	Tier Three	100000	1	2	2	Tier Three	111000000010010000000	30	90								30			90								31	1	Tier Three	2	Tier Three																						Tier Three	60.00	180.00								60.00			120.00								60.00			
H3044	004	0	1	02	01	H3044_004_0	4	2	4	1	Tier Two	000011	1	2	1	Tier Two	111000000010010000000	30	90								30			90								31	1	Tier Two	2	Tier Two																						Tier Two	30.00	90.00								30.00			60.00								30.00			
H3044	004	0	1	02	01	H3044_004_0	4	1	4	1	Tier One	011100	1	2	2	Tier One	111000000010010000000	30	90								30			90								31	1	Tier One	2	Tier One																						Tier One	4.00	12.00								4.00			4.00								4.00			
H3044	004	0	1	02	01	H3044_004_0	4	4	4	3	Tier Four - Specialty	100001	1	1	2																																																																							2		
H3044	004	0	1	02	01	H3044_004_0	4	1	4	3	Tier One	011100	1	2	2	Tier One	111000000010010000000	30	90								30			90								31	1	Tier One	2	Tier One																						Tier One	4.00	12.00								4.00			4.00								4.00	1	1	
H3044	004	0	1	02	01	H3044_004_0	4	4	4	1	Tier Four - Specialty	100001	1	1	2	Tier Four - Specialty	111000000010010000000	30	90								30			90								31	1	Tier Four - Specialty	1	Tier Four - Specialty	25	25								25			25								25	Tier Four - Specialty																								
H3044	004	0	1	02	01	H3044_004_0	4	3	4	3	Tier Three	100000	1	2	2	Tier Three																								Tier Three		Tier Three																						Tier Three																						2		
H3044	004	0	1	02	01	H3044_004_0	4	2	4	3	Tier Two	000011	1	2	1	Tier Two																								Tier Two		Tier Two																						Tier Two																						2		
H3059	002	0	1	01	01	H3059_002_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H3059	002	0	1	01	01	H3059_002_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H3059	002	0	1	01	01	H3059_002_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H3059	002	0	1	01	01	H3059_002_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H3059	005	0	1	01	01	H3059_005_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H3059	005	0	1	01	01	H3059_005_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			60.00								25.00			
H3059	005	0	1	01	01	H3059_005_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H3059	005	0	1	01	01	H3059_005_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H3107	004	0	1	02	01	H3107_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3107	004	0	1	02	01	H3107_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3107	004	0	1	02	01	H3107_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3107	004	0	1	02	01	H3107_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3107	005	0	1	02	01	H3107_005_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3107	005	0	1	02	01	H3107_005_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3107	005	0	1	02	01	H3107_005_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3107	005	0	1	02	01	H3107_005_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3152	022	0	1	01	01	H3152_022_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H3152	022	0	1	01	01	H3152_022_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H3152	022	0	1	01	01	H3152_022_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					64.00			96.00		32.00			
H3152	022	0	1	01	01	H3152_022_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				78.00	195.00		78.00	234.00			78.00					156.00			234.00		78.00			
H3152	022	0	1	01	01	H3152_022_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				37.00	92.50		37.00	111.00			37.00					74.00			111.00		37.00			
H3152	046	0	1	01	01	H3152_046_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3152	046	0	1	01	01	H3152_046_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3152	046	0	1	01	01	H3152_046_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				78.00	195.00		78.00	234.00			78.00					156.00			234.00		78.00			
H3152	046	0	1	01	01	H3152_046_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H3152	046	0	1	01	01	H3152_046_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H3152	048	0	1	01	01	H3152_048_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	048	0	1	01	01	H3152_048_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3152	048	0	1	01	01	H3152_048_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3152	048	0	1	01	01	H3152_048_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H3152	048	0	1	01	01	H3152_048_0	7	4	4	1	Tier 4 - Non-Preferred Brand	000100	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3152	048	0	1	01	01	H3152_048_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H3152	048	0	1	01	01	H3152_048_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3152	048	0	1	01	01	H3152_048_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																						2		
H3152	048	0	1	01	01	H3152_048_0	7	4	4	3	Tier 4 - Non-Preferred Brand	000100	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3152	048	0	1	01	01	H3152_048_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3152	053	0	1	01	01	H3152_053_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3152	053	0	1	01	01	H3152_053_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3152	053	0	1	01	01	H3152_053_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				85.00	212.50		85.00	255.00			85.00					170.00			255.00		85.00			
H3152	053	0	1	01	01	H3152_053_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H3152	053	0	1	01	01	H3152_053_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	074	0	1	01	01	H3152_074_0	8	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				20.00	50.00		20.00	60.00			20.00					40.00			60.00		20.00			
H3152	074	0	1	01	01	H3152_074_0	8	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H3152	074	0	1	01	01	H3152_074_0	8	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3152	074	0	1	01	01	H3152_074_0	8	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	074	0	1	01	01	H3152_074_0	8	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3154	004	0	1	01	01	H3154_004_0	5	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00			
H3154	004	0	1	01	01	H3154_004_0	5	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00			114.00								38.00			
H3154	004	0	1	01	01	H3154_004_0	5	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00			
H3154	004	0	1	01	01	H3154_004_0	5	4	2	1	Specialty	000010		1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3154	006	0	1	02	01	H3154_006_0	5	4	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3154	006	0	1	02	01	H3154_006_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3154	006	0	1	02	01	H3154_006_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3154	006	0	1	02	01	H3154_006_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00	1	1	
H3154	006	0	1	02	01	H3154_006_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00			
H3154	006	0	1	02	01	H3154_006_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00			111.00								37.00			
H3154	006	0	1	02	01	H3154_006_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00			
H3154	006	0	1	02	01	H3154_006_0	5	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H3154	012	0	1	02	01	H3154_012_0	5	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			15.00								10.00			
H3154	012	0	1	02	01	H3154_012_0	5	4	2	1	Specialty	000010		1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3154	012	0	1	02	01	H3154_012_0	5	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	43.00	129.00								43.00			129.00								43.00			
H3154	012	0	1	02	01	H3154_012_0	5	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	86.00	258.00								86.00			258.00								86.00			
H3154	016	0	1	01	01	H3154_016_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00	1	1	
H3154	016	0	1	01	01	H3154_016_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3154	016	0	1	01	01	H3154_016_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3154	016	0	1	01	01	H3154_016_0	5	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H3154	016	0	1	01	01	H3154_016_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00			
H3154	016	0	1	01	01	H3154_016_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00			
H3154	016	0	1	01	01	H3154_016_0	5	4	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3154	016	0	1	01	01	H3154_016_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00			111.00								37.00			
H3204	001	0	1	01	01	H3204_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H3204	001	0	1	01	01	H3204_001_0	7	4	4	1	Specialty	010010	1	1	1	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	30									30											30	Specialty																								
H3204	001	0	1	01	01	H3204_001_0	7	3	4	1	Non-Preferred	100100	1	2	2	Non-Preferred	111000000010010000000	30	90								30			90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	60.00	180.00								60.00			180.00								60.00			
H3204	001	0	1	01	01	H3204_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H3204	007	0	1	01	01	H3204_007_0	8	3	4	1	Non-Preferred	100100	1	2	2	Non-Preferred	111000000010010000000	30	90								30			90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	60.00	180.00								60.00			180.00								60.00			
H3204	007	0	1	01	01	H3204_007_0	8	4	4	1	Specialty	010010	1	1	1	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	30									30											30	Specialty																								
H3204	007	0	1	01	01	H3204_007_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H3204	007	0	1	01	01	H3204_007_0	8	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3204	007	0	1	01	01	H3204_007_0	8	3	4	3	Non-Preferred	100100	1	2	2	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H3204	007	0	1	01	01	H3204_007_0	8	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H3204	007	0	1	01	01	H3204_007_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H3204	007	0	1	01	01	H3204_007_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H3206	001	0	1	04	01	H3206_001_0	7	3	4	1	Non-Preferred	100100	1	2	2	Non-Preferred	111000000010010000000	30	90								30			90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	60.00	180.00								60.00			180.00								60.00			
H3206	001	0	1	04	01	H3206_001_0	7	4	4	1	Specialty	010010	1	1	1	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	30									30											30	Specialty																								
H3206	001	0	1	04	01	H3206_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H3206	001	0	1	04	01	H3206_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H3206	002	0	1	04	01	H3206_002_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H3206	002	0	1	04	01	H3206_002_0	8	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H3206	002	0	1	04	01	H3206_002_0	8	4	4	1	Specialty	010010	1	1	1	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	30									30											30	Specialty																								
H3206	002	0	1	04	01	H3206_002_0	8	3	4	1	Non-Preferred	100100	1	2	2	Non-Preferred	111000000010010000000	30	90								30			90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	60.00	180.00								60.00			180.00								60.00			
H3206	002	0	1	04	01	H3206_002_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H3206	002	0	1	04	01	H3206_002_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H3206	002	0	1	04	01	H3206_002_0	8	3	4	3	Non-Preferred	100100	1	2	2	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H3206	002	0	1	04	01	H3206_002_0	8	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3240	008	0	1	01	01	H3240_008_0	7	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00	60.00							30.00		30.00	60.00	45.00							30.00			
H3240	008	0	1	01	01	H3240_008_0	7	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H3240	008	0	1	01	01	H3240_008_0	7	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H3240	008	0	1	01	01	H3240_008_0	7	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H3240	008	0	1	01	01	H3240_008_0	7	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H3240	008	0	1	01	01	H3240_008_0	7	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3240	008	0	1	01	01	H3240_008_0	7	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3240	008	0	1	01	01	H3240_008_0	7	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3240	008	0	1	01	01	H3240_008_0	7	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H3240	008	0	1	01	01	H3240_008_0	7	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	3.00	9.00	6.00							3.00		3.00	6.00	4.50							3.00			
H3240	010	0	1	01	01	H3240_010_0	6	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00	60.00							30.00		30.00	60.00	45.00							30.00			
H3240	010	0	1	01	01	H3240_010_0	6	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H3240	010	0	1	01	01	H3240_010_0	6	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	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	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H3240	010	0	1	01	01	H3240_010_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H3240	010	0	1	01	01	H3240_010_0	6	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3240	010	0	1	01	01	H3240_010_0	6	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3240	010	0	1	01	01	H3240_010_0	6	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3240	010	0	1	01	01	H3240_010_0	6	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	3.00	9.00	6.00							3.00		3.00	6.00	4.50							3.00			
H3240	010	0	1	01	01	H3240_010_0	6	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H3240	013	0	1	01	01	H3240_013_0	7	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3240	013	0	1	01	01	H3240_013_0	7	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3240	013	0	1	01	01	H3240_013_0	7	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3240	013	0	1	01	01	H3240_013_0	7	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H3240	013	0	1	01	01	H3240_013_0	7	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H3240	013	0	1	01	01	H3240_013_0	7	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H3240	013	0	1	01	01	H3240_013_0	7	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H3240	013	0	1	01	01	H3240_013_0	7	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H3240	013	0	1	01	01	H3240_013_0	7	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	7	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H3251	002	0	1	01	01	H3251_002_0	8	2	4	1	Preferred Brand	000101	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	108.00									36.00		108.00								36.00			
H3251	002	0	1	01	01	H3251_002_0	8	3	4	1	Non-Preferred	110100	1	2	2	Non-Preferred	111000000001010000000	30	90									29		90								31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	70.00	210.00									70.00		210.00								70.00			
H3251	002	0	1	01	01	H3251_002_0	8	4	4	1	Specialty Drug	111111	1	1	1	Specialty Drug	111000000001000000000	30	90									29										31	2	Specialty Drug	4	Specialty Drug	33	33									33										33	Specialty Drug	350.00	1050.00									350.00										350.00			
H3251	002	0	1	01	01	H3251_002_0	8	1	4	3	Preferred Generic	001001	1	2	2	Preferred Generic	111000000001010000000	30	90									29		90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00									10.00		30.00								10.00	1	1	
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																						2		
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																						2		
H3251	002	0	1	01	01	H3251_002_0	8	4	4	3	Specialty Drug	111111	1	1	1	Specialty Drug																								Specialty Drug		Specialty Drug																						Specialty Drug																						2		
H3251	002	0	1	01	01	H3251_002_0	8	1	4	1	Preferred Generic	001001	1	2	2	Preferred Generic	111000000001010000000	30	90									29		90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00									10.00		30.00								10.00			
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																						2		
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																						2		
H3251	021	0	1	01	01	H3251_021_0	8	1	4	3	Preferred Generic	001001	1	2	2	Preferred Generic	111000000001010000000	30	90									29		90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00									10.00		30.00								10.00	1	1	
H3251	021	0	1	01	01	H3251_021_0	8	4	4	1	Specialty Drug	111111	1	1	1	Specialty Drug	111000000001000000000	30	90									29										31	2	Specialty Drug	4	Specialty Drug	33	33									33										33	Specialty Drug	350.00	1050.00									350.00										350.00			
H3251	021	0	1	01	01	H3251_021_0	8	3	4	1	Non-Preferred	110100	1	2	2	Non-Preferred	111000000001010000000	30	90									29		90								31	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	70.00	210.00									70.00		210.00								70.00			
H3251	021	0	1	01	01	H3251_021_0	8	2	4	1	Preferred Brand	000101	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	108.00									36.00		108.00								36.00			
H3251	021	0	1	01	01	H3251_021_0	8	1	4	1	Preferred Generic	001001	1	2	2	Preferred Generic	111000000001010000000	30	90									29		90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00									10.00		30.00								10.00			
H3251	021	0	1	01	01	H3251_021_0	8	4	4	3	Specialty Drug	111111	1	1	1	Specialty Drug																								Specialty Drug		Specialty Drug																						Specialty Drug																						2		
H3305	011	0	1	01	01	H3305_011_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00		60.00	60.00								30.00			
H3305	011	0	1	01	01	H3305_011_0	8	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00		170.00	170.00								85.00			
H3305	011	0	1	01	01	H3305_011_0	8	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H3305	011	0	1	01	01	H3305_011_0	8	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H3305	011	0	1	01	01	H3305_011_0	8	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	9.00	27.00								9.00		18.00	18.00								9.00			
H3305	015	0	1	01	01	H3305_015_0	10	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H3305	015	0	1	01	01	H3305_015_0	10	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00		170.00	170.00								85.00			
H3305	015	0	1	01	01	H3305_015_0	10	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00		60.00	60.00								30.00			
H3305	015	0	1	01	01	H3305_015_0	10	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	9.00	27.00								9.00		18.00	18.00								9.00			
H3305	015	0	1	01	01	H3305_015_0	10	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H3307	002	0	1	01	01	H3307_002_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3307	002	0	1	01	01	H3307_002_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3307	002	0	1	01	01	H3307_002_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3307	002	0	1	01	01	H3307_002_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3307	011	0	1	01	01	H3307_011_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3307	011	0	1	01	01	H3307_011_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3307	011	0	1	01	01	H3307_011_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3307	011	0	1	01	01	H3307_011_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3307	012	0	1	01	01	H3307_012_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3307	012	0	1	01	01	H3307_012_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3307	012	0	1	01	01	H3307_012_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3307	012	0	1	01	01	H3307_012_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3307	015	0	1	01	01	H3307_015_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3307	015	0	1	01	01	H3307_015_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3307	015	0	1	01	01	H3307_015_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3307	015	0	1	01	01	H3307_015_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3307	021	0	1	01	01	H3307_021_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3307	021	0	1	01	01	H3307_021_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3307	021	0	1	01	01	H3307_021_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	8.00	24.00								8.00						16.00			24.00		8.00			
H3307	021	0	1	01	01	H3307_021_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3307	022	0	1	01	01	H3307_022_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3307	022	0	1	01	01	H3307_022_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3307	022	0	1	01	01	H3307_022_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H3307	022	0	1	01	01	H3307_022_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3312	002	0	1	01	01	H3312_002_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	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	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H3312	002	0	1	01	01	H3312_002_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					68.00			102.00		34.00			
H3312	002	0	1	01	01	H3312_002_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	74.00	222.00									74.00					148.00			222.00		74.00			
H3312	002	0	1	01	01	H3312_002_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	018	0	1	01	01	H3312_018_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	018	0	1	01	01	H3312_018_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H3312	018	0	1	01	01	H3312_018_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H3312	018	0	1	01	01	H3312_018_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3312	018	0	1	01	01	H3312_018_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00			
H3312	025	0	1	01	01	H3312_025_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	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	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	025	0	1	01	01	H3312_025_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	77.00	231.00									77.00					154.00			231.00		77.00			
H3312	025	0	1	01	01	H3312_025_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H3312	025	0	1	01	01	H3312_025_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3312	028	0	1	01	01	H3312_028_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	028	0	1	01	01	H3312_028_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H3312	028	0	1	01	01	H3312_028_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3312	028	0	1	01	01	H3312_028_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																						2		
H3312	028	0	1	01	01	H3312_028_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3312	028	0	1	01	01	H3312_028_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3312	028	0	1	01	01	H3312_028_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3312	028	0	1	01	01	H3312_028_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	028	0	1	01	01	H3312_028_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H3312	028	0	1	01	01	H3312_028_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	043	0	1	01	01	H3312_043_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3312	043	0	1	01	01	H3312_043_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	71.00	213.00									71.00					142.00			213.00		71.00			
H3312	043	0	1	01	01	H3312_043_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	043	0	1	01	01	H3312_043_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	29.00	87.00									29.00					58.00			87.00		29.00			
H3312	043	0	1	01	01	H3312_043_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	9.00	27.00									9.00					18.00			27.00		9.00			
H3312	044	0	1	01	01	H3312_044_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3312	044	0	1	01	01	H3312_044_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3312	044	0	1	01	01	H3312_044_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																						2		
H3312	044	0	1	01	01	H3312_044_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3312	044	0	1	01	01	H3312_044_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H3312	044	0	1	01	01	H3312_044_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3312	044	0	1	01	01	H3312_044_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	044	0	1	01	01	H3312_044_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H3312	044	0	1	01	01	H3312_044_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	044	0	1	01	01	H3312_044_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	048	0	1	01	01	H3312_048_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H3312	048	0	1	01	01	H3312_048_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	048	0	1	01	01	H3312_048_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H3312	048	0	1	01	01	H3312_048_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H3312	048	0	1	01	01	H3312_048_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3312	052	0	1	01	01	H3312_052_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3312	052	0	1	01	01	H3312_052_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	052	0	1	01	01	H3312_052_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
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																						2		
H3312	052	0	1	01	01	H3312_052_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
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																						2		
H3312	052	0	1	01	01	H3312_052_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3312	052	0	1	01	01	H3312_052_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	052	0	1	01	01	H3312_052_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	052	0	1	01	01	H3312_052_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H3312	055	0	1	01	01	H3312_055_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3312	055	0	1	01	01	H3312_055_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3312	055	0	1	01	01	H3312_055_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3312	055	0	1	01	01	H3312_055_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3312	055	0	1	01	01	H3312_055_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																						2		
H3312	055	0	1	01	01	H3312_055_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	055	0	1	01	01	H3312_055_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	055	0	1	01	01	H3312_055_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H3312	055	0	1	01	01	H3312_055_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	055	0	1	01	01	H3312_055_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H3312	057	0	1	01	01	H3312_057_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3312	057	0	1	01	01	H3312_057_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H3312	057	0	1	01	01	H3312_057_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	057	0	1	01	01	H3312_057_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	33.00	99.00									33.00					66.00			99.00		33.00			
H3312	057	0	1	01	01	H3312_057_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H3312	058	0	1	01	01	H3312_058_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3312	058	0	1	01	01	H3312_058_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3312	058	0	1	01	01	H3312_058_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																						2		
H3312	058	0	1	01	01	H3312_058_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3312	058	0	1	01	01	H3312_058_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H3312	058	0	1	01	01	H3312_058_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	058	0	1	01	01	H3312_058_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	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	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	058	0	1	01	01	H3312_058_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3312	058	0	1	01	01	H3312_058_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	059	0	1	01	01	H3312_059_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3312	059	0	1	01	01	H3312_059_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3312	059	0	1	01	01	H3312_059_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H3312	059	0	1	01	01	H3312_059_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3312	059	0	1	01	01	H3312_059_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H3312	059	0	1	01	01	H3312_059_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3312	059	0	1	01	01	H3312_059_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3312	059	0	1	01	01	H3312_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																						2		
H3312	059	0	1	01	01	H3312_059_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3312	059	0	1	01	01	H3312_059_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3327	001	0	1	01	01	H3327_001_0	9	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00			
H3327	001	0	1	01	01	H3327_001_0	9	4	4	1	Biological and Specialty Injectables	010010	1	1	2	Biological and Specialty Injectables	111000000010010000000	31	90								31			90								31	1	Biological and Specialty Injectables	1	Biological and Specialty Injectables	25	25								25			25								25	Biological and Specialty Injectables																								
H3327	001	0	1	01	01	H3327_001_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3327	001	0	1	01	01	H3327_001_0	9	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3327	001	0	1	01	01	H3327_001_0	9	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3327	001	0	1	01	01	H3327_001_0	9	3	4	3	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3327	001	0	1	01	01	H3327_001_0	9	4	4	3	Biological and Specialty Injectables	010010	1	1	2	Biological and Specialty Injectables																								Biological and Specialty Injectables		Biological and Specialty Injectables																						Biological and Specialty Injectables																						2		
H3327	002	0	1	01	01	H3327_002_0	6	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00			
H3327	002	0	1	01	01	H3327_002_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3327	002	0	1	01	01	H3327_002_0	6	4	4	1	Biological and Specialty Injectables	010010	1	1	2	Biological and Specialty Injectables	111000000010010000000	31	90								31			90								31	1	Biological and Specialty Injectables	1	Biological and Specialty Injectables	25	25								25			25								25	Biological and Specialty Injectables																								
H3327	002	0	1	01	01	H3327_002_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3327	002	0	1	01	01	H3327_002_0	6	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3327	002	0	1	01	01	H3327_002_0	6	3	4	3	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3327	002	0	1	01	01	H3327_002_0	6	4	4	3	Biological and Specialty Injectables	010010	1	1	2	Biological and Specialty Injectables																								Biological and Specialty Injectables		Biological and Specialty Injectables																						Biological and Specialty Injectables																						2		
H3327	021	0	1	01	01	H3327_021_0	5	4	2	1	Biological and Specialty Injectables	010010		1	2	Biological and Specialty Injectables	111000000010010000000	31	90								31			90								31	1	Biological and Specialty Injectables	1	Biological and Specialty Injectables	25	25								25			25								25	Biological and Specialty Injectables																								
H3327	021	0	1	01	01	H3327_021_0	5	3	2	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00			110.00								55.00			
H3327	021	0	1	01	01	H3327_021_0	5	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	6.00	18.00								6.00			12.00								6.00			
H3327	021	0	1	01	01	H3327_021_0	5	2	2	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00			
H3327	023	0	1	02	01	H3327_023_0	6	4	4	3	Biological and Specialty Injectables	010010	1	1	2	Biological and Specialty Injectables																								Biological and Specialty Injectables		Biological and Specialty Injectables																						Biological and Specialty Injectables																						2		
H3327	023	0	1	02	01	H3327_023_0	6	4	4	1	Biological and Specialty Injectables	010010	1	1	2	Biological and Specialty Injectables	111000000010010000000	31	90								31			90								31	1	Biological and Specialty Injectables	1	Biological and Specialty Injectables	25	25								25			25								25	Biological and Specialty Injectables																								
H3327	023	0	1	02	01	H3327_023_0	6	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3327	023	0	1	02	01	H3327_023_0	6	3	4	3	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3327	023	0	1	02	01	H3327_023_0	6	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			50.00								25.00			
H3327	023	0	1	02	01	H3327_023_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3327	023	0	1	02	01	H3327_023_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3328	002	0	1	01	01	H3328_002_0	4	3	2	1	Non-preferred Brand	100000		2	2	Non-preferred Brand	111000000010010000000	30	90								30			90								34	1	Non-preferred Brand	1	Non-preferred Brand	50	50								50			50								50	Non-preferred Brand																								
H3328	002	0	1	01	01	H3328_002_0	4	2	2	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	1	Preferred Brand	37	37								37			37								37	Preferred Brand																								
H3328	002	0	1	01	01	H3328_002_0	4	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	1	Generic	0	0								0			0								0	Generic																								
H3328	002	0	1	01	01	H3328_002_0	4	4	2	1	Specialty	000001		1	2	Specialty	111000000010010000000	30	90								30			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3328	003	0	1	02	01	H3328_003_0	5	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	6.00	18.00								6.00			18.00								6.00			
H3328	003	0	1	02	01	H3328_003_0	5	2	2	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00			
H3328	003	0	1	02	01	H3328_003_0	5	3	2	1	Non-preferred Brand	100000		2	2	Non-preferred Brand	111000000010010000000	30	90								30			90								34	1	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand	55.00	165.00								55.00			165.00								55.00			
H3328	003	0	1	02	01	H3328_003_0	5	4	2	1	Specialty	000001		1	2	Specialty	111000000010010000000	30	90								30			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3328	012	0	1	02	01	H3328_012_0	4	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3328	012	0	1	02	01	H3328_012_0	4	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3328	012	0	1	02	01	H3328_012_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			8.00								4.00	1	1	
H3328	012	0	1	02	01	H3328_012_0	4	4	4	1	Specialty	000001	1	1	2	Specialty	111000000010010000000	30	90								30			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3328	012	0	1	02	01	H3328_012_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			8.00								4.00			
H3328	012	0	1	02	01	H3328_012_0	4	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3328	012	0	1	02	01	H3328_012_0	4	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								34	1	Non-Preferred Brand	1	Non-Preferred Brand	60	60								60			50								60	Non-Preferred Brand																								
H3328	012	0	1	02	01	H3328_012_0	4	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	1	Preferred Brand	40	40								40			30								40	Preferred Brand																								
H3328	013	0	1	01	01	H3328_013_0	4	4	3	1	Specialty	000001		1	2	Specialty	111000000010010000000	30	90								30			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3328	013	0	1	01	01	H3328_013_0	4	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								34	1	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55			45								55	Non-Preferred Brand																								
H3328	013	0	1	01	01	H3328_013_0	4	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	1	Preferred Brand	10	10								10			0								10	Preferred Brand																								
H3328	013	0	1	01	01	H3328_013_0	4	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3328	014	0	1	02	01	H3328_014_0	4	4	2	1	Specialty	000001		1	2	Specialty	111000000010010000000	30	90								30			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3328	014	0	1	02	01	H3328_014_0	4	2	2	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			90.00								45.00			
H3328	014	0	1	02	01	H3328_014_0	4	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H3328	014	0	1	02	01	H3328_014_0	4	3	2	1	Non-preferred Brand	100000		2	2	Non-preferred Brand	111000000010010000000	30	90								30			90								34	1	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand	95.00	285.00								95.00			190.00								95.00			
H3330	021	1	1	01	01	H3330_021_1	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	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	5	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	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	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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	5	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	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	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	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	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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	5	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	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	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	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	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
H3330	023	1	1	01	01	H3330_023_1	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	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	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	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	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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	4	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	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	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	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	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H3330	029	0	1	01	01	H3330_029_0	3	3	2	1	Tier 3	100100		2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	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	3	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
H3330	029	0	1	01	01	H3330_029_0	3	2	2	1	Tier 2	000001		2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	3	4	2	1	Tier 4	010010		1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H3330	031	1	1	01	01	H3330_031_1	4	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
H3330	031	1	1	01	01	H3330_031_1	4	4	2	1	Tier 4	010010		1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H3330	031	1	1	01	01	H3330_031_1	4	2	2	1	Tier 2	000001		2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	4	3	2	1	Tier 3	100100		2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																								
H3330	031	2	1	01	01	H3330_031_2	3	4	2	1	Tier 4	010010		1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	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	3	3	2	1	Tier 3	100100		2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																								
H3330	031	2	1	01	01	H3330_031_2	3	2	2	1	Tier 2	000001		2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 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	3	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
H3333	049	0	1	09	04	H3333_049_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	049	0	1	09	04	H3333_049_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	049	0	1	09	04	H3333_049_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	049	0	1	09	04	H3333_049_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	049	0	1	09	04	H3333_049_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	049	0	1	09	04	H3333_049_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	049	0	1	09	04	H3333_049_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	049	0	1	09	04	H3333_049_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	050	0	1	09	04	H3333_050_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	050	0	1	09	04	H3333_050_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	050	0	1	09	04	H3333_050_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	050	0	1	09	04	H3333_050_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	050	0	1	09	04	H3333_050_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	050	0	1	09	04	H3333_050_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	050	0	1	09	04	H3333_050_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	050	0	1	09	04	H3333_050_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	051	0	1	09	04	H3333_051_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	051	0	1	09	04	H3333_051_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	051	0	1	09	04	H3333_051_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	051	0	1	09	04	H3333_051_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	051	0	1	09	04	H3333_051_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	051	0	1	09	04	H3333_051_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	051	0	1	09	04	H3333_051_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	051	0	1	09	04	H3333_051_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	052	0	1	09	04	H3333_052_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	052	0	1	09	04	H3333_052_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	052	0	1	09	04	H3333_052_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	052	0	1	09	04	H3333_052_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	052	0	1	09	04	H3333_052_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	052	0	1	09	04	H3333_052_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	052	0	1	09	04	H3333_052_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	052	0	1	09	04	H3333_052_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	053	0	1	09	04	H3333_053_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	053	0	1	09	04	H3333_053_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	053	0	1	09	04	H3333_053_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	053	0	1	09	04	H3333_053_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	053	0	1	09	04	H3333_053_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	053	0	1	09	04	H3333_053_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	053	0	1	09	04	H3333_053_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	053	0	1	09	04	H3333_053_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	054	0	1	09	04	H3333_054_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	054	0	1	09	04	H3333_054_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	054	0	1	09	04	H3333_054_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	054	0	1	09	04	H3333_054_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	054	0	1	09	04	H3333_054_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	054	0	1	09	04	H3333_054_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	054	0	1	09	04	H3333_054_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	054	0	1	09	04	H3333_054_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	055	0	1	09	04	H3333_055_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	055	0	1	09	04	H3333_055_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	055	0	1	09	04	H3333_055_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	055	0	1	09	04	H3333_055_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	056	0	1	09	04	H3333_056_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	056	0	1	09	04	H3333_056_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	056	0	1	09	04	H3333_056_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	056	0	1	09	04	H3333_056_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	057	0	1	09	04	H3333_057_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	057	0	1	09	04	H3333_057_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	057	0	1	09	04	H3333_057_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	057	0	1	09	04	H3333_057_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	058	0	1	09	04	H3333_058_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	058	0	1	09	04	H3333_058_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	058	0	1	09	04	H3333_058_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	058	0	1	09	04	H3333_058_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	059	0	1	09	04	H3333_059_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	059	0	1	09	04	H3333_059_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	059	0	1	09	04	H3333_059_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	059	0	1	09	04	H3333_059_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	060	0	1	09	04	H3333_060_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	060	0	1	09	04	H3333_060_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	060	0	1	09	04	H3333_060_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	060	0	1	09	04	H3333_060_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	105	0	1	09	04	H3333_105_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	105	0	1	09	04	H3333_105_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	105	0	1	09	04	H3333_105_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	105	0	1	09	04	H3333_105_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	105	0	1	09	04	H3333_105_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	105	0	1	09	04	H3333_105_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	105	0	1	09	04	H3333_105_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	105	0	1	09	04	H3333_105_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	107	0	1	09	04	H3333_107_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	107	0	1	09	04	H3333_107_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	107	0	1	09	04	H3333_107_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	107	0	1	09	04	H3333_107_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	113	0	1	09	04	H3333_113_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	113	0	1	09	04	H3333_113_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	113	0	1	09	04	H3333_113_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	113	0	1	09	04	H3333_113_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	113	0	1	09	04	H3333_113_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	113	0	1	09	04	H3333_113_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	113	0	1	09	04	H3333_113_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	113	0	1	09	04	H3333_113_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	115	0	1	09	04	H3333_115_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	115	0	1	09	04	H3333_115_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	115	0	1	09	04	H3333_115_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	115	0	1	09	04	H3333_115_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	121	0	1	09	04	H3333_121_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	121	0	1	09	04	H3333_121_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	121	0	1	09	04	H3333_121_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	121	0	1	09	04	H3333_121_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	121	0	1	09	04	H3333_121_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	121	0	1	09	04	H3333_121_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	121	0	1	09	04	H3333_121_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	121	0	1	09	04	H3333_121_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	123	0	1	09	04	H3333_123_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	123	0	1	09	04	H3333_123_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	123	0	1	09	04	H3333_123_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	123	0	1	09	04	H3333_123_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	129	0	1	09	04	H3333_129_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	129	0	1	09	04	H3333_129_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	129	0	1	09	04	H3333_129_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	129	0	1	09	04	H3333_129_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	129	0	1	09	04	H3333_129_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	129	0	1	09	04	H3333_129_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	129	0	1	09	04	H3333_129_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	129	0	1	09	04	H3333_129_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	137	0	1	09	04	H3333_137_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3333	137	0	1	09	04	H3333_137_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	137	0	1	09	04	H3333_137_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	137	0	1	09	04	H3333_137_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	137	0	1	09	04	H3333_137_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	137	0	1	09	04	H3333_137_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	137	0	1	09	04	H3333_137_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	137	0	1	09	04	H3333_137_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	145	0	1	09	04	H3333_145_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H3333	145	0	1	09	04	H3333_145_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H3333	145	0	1	09	04	H3333_145_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H3333	145	0	1	09	04	H3333_145_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H3333	145	0	1	09	04	H3333_145_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H3333	145	0	1	09	04	H3333_145_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3333	145	0	1	09	04	H3333_145_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3333	145	0	1	09	04	H3333_145_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3335	002	0	1	04	01	H3335_002_0	5	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	002	0	1	04	01	H3335_002_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	002	0	1	04	01	H3335_002_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	002	0	1	04	01	H3335_002_0	5	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	005	0	1	04	01	H3335_005_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	005	0	1	04	01	H3335_005_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	005	0	1	04	01	H3335_005_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	005	0	1	04	01	H3335_005_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	005	0	1	04	01	H3335_005_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00	1	1	
H3335	005	0	1	04	01	H3335_005_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3335	005	0	1	04	01	H3335_005_0	6	3	4	3	Tier 3	100000	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3335	005	0	1	04	01	H3335_005_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3335	006	0	1	04	01	H3335_006_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	006	0	1	04	01	H3335_006_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	006	0	1	04	01	H3335_006_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	006	0	1	04	01	H3335_006_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	008	0	1	04	01	H3335_008_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	008	0	1	04	01	H3335_008_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3335	008	0	1	04	01	H3335_008_0	6	3	4	3	Tier 3	100000	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3335	008	0	1	04	01	H3335_008_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3335	008	0	1	04	01	H3335_008_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	008	0	1	04	01	H3335_008_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	008	0	1	04	01	H3335_008_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00	1	1	
H3335	008	0	1	04	01	H3335_008_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	009	0	1	04	01	H3335_009_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	009	0	1	04	01	H3335_009_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	009	0	1	04	01	H3335_009_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	009	0	1	04	01	H3335_009_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	014	0	1	04	01	H3335_014_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	014	0	1	04	01	H3335_014_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	014	0	1	04	01	H3335_014_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	014	0	1	04	01	H3335_014_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3335	014	0	1	04	01	H3335_014_0	6	3	4	3	Tier 3	100000	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3335	014	0	1	04	01	H3335_014_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	014	0	1	04	01	H3335_014_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00	1	1	
H3335	014	0	1	04	01	H3335_014_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3335	015	0	1	04	01	H3335_015_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	015	0	1	04	01	H3335_015_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	015	0	1	04	01	H3335_015_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	015	0	1	04	01	H3335_015_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	017	0	1	04	01	H3335_017_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	017	0	1	04	01	H3335_017_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	017	0	1	04	01	H3335_017_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	017	0	1	04	01	H3335_017_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	017	0	1	04	01	H3335_017_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00	1	1	
H3335	017	0	1	04	01	H3335_017_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3335	017	0	1	04	01	H3335_017_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3335	017	0	1	04	01	H3335_017_0	6	3	4	3	Tier 3	100000	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3335	018	0	1	04	01	H3335_018_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	018	0	1	04	01	H3335_018_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	018	0	1	04	01	H3335_018_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	018	0	1	04	01	H3335_018_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	020	0	1	04	01	H3335_020_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	020	0	1	04	01	H3335_020_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	020	0	1	04	01	H3335_020_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3335	020	0	1	04	01	H3335_020_0	6	3	4	3	Tier 3	100000	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3335	020	0	1	04	01	H3335_020_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3335	020	0	1	04	01	H3335_020_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00	1	1	
H3335	020	0	1	04	01	H3335_020_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	020	0	1	04	01	H3335_020_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	021	0	1	04	01	H3335_021_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	021	0	1	04	01	H3335_021_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	021	0	1	04	01	H3335_021_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3335	021	0	1	04	01	H3335_021_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	032	0	1	04	01	H3335_032_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	032	0	1	04	01	H3335_032_0	4	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	032	0	1	04	01	H3335_032_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	032	0	1	04	01	H3335_032_0	4	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	036	0	1	04	01	H3335_036_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	036	0	1	04	01	H3335_036_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	036	0	1	04	01	H3335_036_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	036	0	1	04	01	H3335_036_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	037	0	1	04	01	H3335_037_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	037	0	1	04	01	H3335_037_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	037	0	1	04	01	H3335_037_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	037	0	1	04	01	H3335_037_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	038	0	1	04	01	H3335_038_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	038	0	1	04	01	H3335_038_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	038	0	1	04	01	H3335_038_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	038	0	1	04	01	H3335_038_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	039	0	1	04	01	H3335_039_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	039	0	1	04	01	H3335_039_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3335	039	0	1	04	01	H3335_039_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	039	0	1	04	01	H3335_039_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	040	0	1	04	01	H3335_040_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3335	040	0	1	04	01	H3335_040_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3335	040	0	1	04	01	H3335_040_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3335	040	0	1	04	01	H3335_040_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3337	001	0	1	01	01	H3337_001_0	6	2	4	3	Generics	000100	3	2	2	Generics	111100000010111000000	31	92	62							31		31	92	62							31	1	Generics	2	Generics																						Generics	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00	1	1	
H3337	001	0	1	01	01	H3337_001_0	6	1	4	3	Preferred Generics	001000	3	2	2	Preferred Generics	111100000010111000000	31	92	62							31		31	92	62							31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H3337	001	0	1	01	01	H3337_001_0	6	6	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	25									25		25									25	Specialty Drugs																								
H3337	001	0	1	01	01	H3337_001_0	6	5	4	1	Brands	100000	1	2	1	Brands	111100000010111000000	31	92	62							31		31	92	62							31	1	Brands	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	6	4	4	1	Preferred Brands	000001	1	2	2	Preferred Brands	111100000010111000000	31	92	62							31		31	92	62							31	1	Preferred Brands	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	6	3	4	3	Liberty Choice Drugs	000010	3	2	2	Liberty Choice Drugs	111100000010111000000	31	92	62							31		31	92	62							31	1	Liberty Choice Drugs	2	Liberty Choice Drugs																						Liberty Choice Drugs	10.00	30.00	20.00							10.00		10.00	30.00	20.00							10.00	1	1	
H3337	001	0	1	01	01	H3337_001_0	6	2	4	1	Generics	000100	3	2	2	Generics	111100000010111000000	31	92	62							31		31	92	62							31	1	Generics	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	6	1	4	1	Preferred Generics	001000	3	2	2	Preferred Generics	111100000010111000000	31	92	62							31		31	92	62							31	1	Preferred Generics	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	6	6	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3337	001	0	1	01	01	H3337_001_0	6	4	4	3	Preferred Brands	000001	1	2	2	Preferred Brands																								Preferred Brands		Preferred Brands																						Preferred Brands																						2		
H3337	001	0	1	01	01	H3337_001_0	6	5	4	3	Brands	100000	1	2	1	Brands																								Brands		Brands																						Brands																						2		
H3337	001	0	1	01	01	H3337_001_0	6	3	4	1	Liberty Choice Drugs	000010	3	2	2	Liberty Choice Drugs	111100000010111000000	31	92	62							31		31	92	62							31	1	Liberty Choice Drugs	2	Liberty Choice Drugs																						Liberty Choice Drugs	10.00	30.00	10.00							10.00		10.00	30.00	20.00							10.00			
H3342	001	0	1	04	01	H3342_001_0	12	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3342	001	0	1	04	01	H3342_001_0	12	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3342	001	0	1	04	01	H3342_001_0	12	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3342	001	0	1	04	01	H3342_001_0	12	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3342	001	0	1	04	01	H3342_001_0	12	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3342	001	0	1	04	01	H3342_001_0	12	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3342	001	0	1	04	01	H3342_001_0	12	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3342	001	0	1	04	01	H3342_001_0	12	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3342	001	0	1	04	01	H3342_001_0	12	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3342	001	0	1	04	01	H3342_001_0	12	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3342	002	0	1	04	01	H3342_002_0	11	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3342	002	0	1	04	01	H3342_002_0	11	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3342	002	0	1	04	01	H3342_002_0	11	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3342	002	0	1	04	01	H3342_002_0	11	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3342	002	0	1	04	01	H3342_002_0	11	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3342	002	0	1	04	01	H3342_002_0	11	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3342	002	0	1	04	01	H3342_002_0	11	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3342	002	0	1	04	01	H3342_002_0	11	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3342	002	0	1	04	01	H3342_002_0	11	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3342	002	0	1	04	01	H3342_002_0	11	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3342	004	0	1	04	01	H3342_004_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3342	004	0	1	04	01	H3342_004_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3342	004	0	1	04	01	H3342_004_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3342	004	0	1	04	01	H3342_004_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3342	004	0	1	04	01	H3342_004_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3342	004	0	1	04	01	H3342_004_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3342	004	0	1	04	01	H3342_004_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3342	004	0	1	04	01	H3342_004_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3342	004	0	1	04	01	H3342_004_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3342	004	0	1	04	01	H3342_004_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3342	012	0	1	04	01	H3342_012_0	12	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3342	012	0	1	04	01	H3342_012_0	12	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3342	012	0	1	04	01	H3342_012_0	12	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3342	012	0	1	04	01	H3342_012_0	12	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3342	012	0	1	04	01	H3342_012_0	12	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3342	012	0	1	04	01	H3342_012_0	12	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3342	012	0	1	04	01	H3342_012_0	12	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3342	012	0	1	04	01	H3342_012_0	12	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3342	012	0	1	04	01	H3342_012_0	12	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3342	012	0	1	04	01	H3342_012_0	12	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3344	001	0	1	04	01	H3344_001_0	8	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00			
H3344	001	0	1	04	01	H3344_001_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			105.00								42.00			
H3344	001	0	1	04	01	H3344_001_0	8	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00											75.00			
H3344	001	0	1	04	01	H3344_001_0	8	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H3344	001	0	1	04	01	H3344_001_0	8	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00	1	2	10001000
H3344	001	0	1	04	01	H3344_001_0	8	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3344	001	0	1	04	01	H3344_001_0	8	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3344	001	0	1	04	01	H3344_001_0	8	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H3344	003	0	1	04	01	H3344_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																						2		
H3344	003	0	1	04	01	H3344_003_0	8	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3344	003	0	1	04	01	H3344_003_0	8	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3344	003	0	1	04	01	H3344_003_0	8	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00	1	2	10001000
H3344	003	0	1	04	01	H3344_003_0	8	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H3344	003	0	1	04	01	H3344_003_0	8	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00											70.00			
H3344	003	0	1	04	01	H3344_003_0	8	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00			
H3344	003	0	1	04	01	H3344_003_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			100.00								40.00			
H3344	005	0	1	04	01	H3344_005_0	12	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3344	005	0	1	04	01	H3344_005_0	12	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3344	005	0	1	04	01	H3344_005_0	12	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00	1	2	10001000
H3344	005	0	1	04	01	H3344_005_0	12	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H3344	005	0	1	04	01	H3344_005_0	12	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00											75.00			
H3344	005	0	1	04	01	H3344_005_0	12	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			112.50								45.00			
H3344	005	0	1	04	01	H3344_005_0	12	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00			
H3344	005	0	1	04	01	H3344_005_0	12	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H3346	002	0	1	04	01	H3346_002_0	12	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00		20.00	20.00								10.00			
H3346	002	0	1	04	01	H3346_002_0	12	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	34.00	102.00								34.00		68.00	68.00								34.00			
H3346	002	0	1	04	01	H3346_002_0	12	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	90.00	270.00								90.00		180.00	180.00								90.00			
H3346	002	0	1	04	01	H3346_002_0	12	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H3346	002	0	1	04	01	H3346_002_0	12	5	4	3	Tier 5	100100	1	2	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
H3346	002	0	1	04	01	H3346_002_0	12	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00		20.00	20.00								10.00	1	1	
H3346	002	0	1	04	01	H3346_002_0	12	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3346	002	0	1	04	01	H3346_002_0	12	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3346	002	0	1	04	01	H3346_002_0	12	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3346	002	0	1	04	01	H3346_002_0	12	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H3347	001	0	1	01	01	H3347_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3347	001	0	1	01	01	H3347_001_0	4	2	4	1	Preferred	000001	1	2	1	Preferred	111000000010010000000	30	90								30			90								31	1	Preferred	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00			
H3347	001	0	1	01	01	H3347_001_0	4	3	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00			
H3347	001	0	1	01	01	H3347_001_0	4	4	4	1	Specialty	100100	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3347	001	0	1	01	01	H3347_001_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3347	001	0	1	01	01	H3347_001_0	4	2	4	3	Preferred	000001	1	2	1	Preferred																								Preferred		Preferred																						Preferred																						2		
H3347	001	0	1	01	01	H3347_001_0	4	3	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H3347	001	0	1	01	01	H3347_001_0	4	4	4	3	Specialty	100100	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3347	005	0	1	01	01	H3347_005_0	4	4	4	3	Specialty	100100	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3347	005	0	1	01	01	H3347_005_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3347	005	0	1	01	01	H3347_005_0	4	3	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H3347	005	0	1	01	01	H3347_005_0	4	2	4	3	Preferred	000001	1	2	1	Preferred																								Preferred		Preferred																						Preferred																						2		
H3347	005	0	1	01	01	H3347_005_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3347	005	0	1	01	01	H3347_005_0	4	4	4	1	Specialty	100100	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3347	005	0	1	01	01	H3347_005_0	4	3	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00			
H3347	005	0	1	01	01	H3347_005_0	4	2	4	1	Preferred	000001	1	2	1	Preferred	111000000010010000000	30	90								30			90								31	1	Preferred	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00			
H3347	010	0	1	02	01	H3347_010_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H3347	010	0	1	02	01	H3347_010_0	4	3	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H3347	010	0	1	02	01	H3347_010_0	4	2	4	3	Preferred	000001	1	2	1	Preferred																								Preferred		Preferred																						Preferred																						2		
H3347	010	0	1	02	01	H3347_010_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3347	010	0	1	02	01	H3347_010_0	4	4	4	1	Specialty	100100	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3347	010	0	1	02	01	H3347_010_0	4	3	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00			
H3347	010	0	1	02	01	H3347_010_0	4	2	4	1	Preferred	000001	1	2	1	Preferred	111000000010010000000	30	90								30			90								31	1	Preferred	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00			
H3347	010	0	1	02	01	H3347_010_0	4	4	4	3	Specialty	100100	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3351	002	0	1	01	01	H3351_002_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3351	002	0	1	01	01	H3351_002_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3351	002	0	1	01	01	H3351_002_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3351	002	0	1	01	01	H3351_002_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3351	006	0	1	01	01	H3351_006_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3351	006	0	1	01	01	H3351_006_0	7	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3351	006	0	1	01	01	H3351_006_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3351	006	0	1	01	01	H3351_006_0	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3351	010	0	1	01	01	H3351_010_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3351	010	0	1	01	01	H3351_010_0	7	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3351	010	0	1	01	01	H3351_010_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3351	010	0	1	01	01	H3351_010_0	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3351	011	0	1	01	01	H3351_011_0	7	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3351	011	0	1	01	01	H3351_011_0	7	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3351	011	0	1	01	01	H3351_011_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3351	011	0	1	01	01	H3351_011_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3351	012	0	1	01	01	H3351_012_0	5	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3351	012	0	1	01	01	H3351_012_0	5	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3351	012	0	1	01	01	H3351_012_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3351	012	0	1	01	01	H3351_012_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3351	013	0	1	01	01	H3351_013_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3351	013	0	1	01	01	H3351_013_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3351	013	0	1	01	01	H3351_013_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3351	013	0	1	01	01	H3351_013_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3356	001	0	1	18	06	H3356_001_0	4	3	3	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
H3356	001	0	1	18	06	H3356_001_0	4	2	3	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
H3356	001	0	1	18	06	H3356_001_0	4	1	3	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
H3356	001	0	1	18	06	H3356_001_0	4	4	3	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3359	001	0	1	01	01	H3359_001_0	9	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	9	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H3359	001	0	1	01	01	H3359_001_0	9	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			200.00								80.00			
H3359	001	0	1	01	01	H3359_001_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3359	031	0	1	01	01	H3359_031_0	9	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	9	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00			
H3359	031	0	1	01	01	H3359_031_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3359	031	0	1	01	01	H3359_031_0	9	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00			
H3359	032	0	1	01	01	H3359_032_0	9	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			100.00								40.00			
H3359	032	0	1	01	01	H3359_032_0	9	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H3359	032	0	1	01	01	H3359_032_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3359	032	0	1	01	01	H3359_032_0	9	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			200.00								80.00			
H3361	043	0	1	02	01	H3361_043_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3361	043	0	1	02	01	H3361_043_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	67.00	201.00								67.00			201.00								67.00			
H3361	043	0	1	02	01	H3361_043_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H3361	065	0	1	01	01	H3361_065_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3361	065	0	1	01	01	H3361_065_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
H3361	065	0	1	01	01	H3361_065_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
H3361	065	0	1	01	01	H3361_065_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H3361	098	0	1	02	01	H3361_098_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3361	098	0	1	02	01	H3361_098_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	81.00	243.00								81.00			243.00								81.00			
H3361	098	0	1	02	01	H3361_098_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H3361	098	0	1	02	01	H3361_098_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H3361	099	0	1	02	01	H3361_099_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H3361	099	0	1	02	01	H3361_099_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3361	099	0	1	02	01	H3361_099_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H3361	105	0	1	01	01	H3361_105_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
H3361	105	0	1	01	01	H3361_105_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	34.00	102.00								34.00			102.00								34.00			
H3361	105	0	1	01	01	H3361_105_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H3361	105	0	1	01	01	H3361_105_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3361	106	0	1	02	01	H3361_106_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00								79.00			237.00								79.00			
H3361	106	0	1	02	01	H3361_106_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
H3361	106	0	1	02	01	H3361_106_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3361	106	0	1	02	01	H3361_106_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H3361	109	0	1	01	01	H3361_109_0	5	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
H3361	109	0	1	01	01	H3361_109_0	5	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00			
H3361	109	0	1	01	01	H3361_109_0	5	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00			
H3361	109	0	1	01	01	H3361_109_0	5	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3362	003	0	1	01	01	H3362_003_0	6	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H3362	003	0	1	01	01	H3362_003_0	6	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3362	003	0	1	01	01	H3362_003_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3362	003	0	1	01	01	H3362_003_0	6	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00	1	2	10001000
H3362	003	0	1	01	01	H3362_003_0	6	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H3362	003	0	1	01	01	H3362_003_0	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00											75.00			
H3362	003	0	1	01	01	H3362_003_0	6	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00			
H3362	003	0	1	01	01	H3362_003_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			112.50								45.00			
H3362	004	0	1	01	01	H3362_004_0	6	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3362	004	0	1	01	01	H3362_004_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3362	004	0	1	01	01	H3362_004_0	6	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00	1	2	10001000
H3362	004	0	1	01	01	H3362_004_0	6	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H3362	004	0	1	01	01	H3362_004_0	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00											65.00			
H3362	004	0	1	01	01	H3362_004_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			105.00								42.00			
H3362	004	0	1	01	01	H3362_004_0	6	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00			
H3362	004	0	1	01	01	H3362_004_0	6	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H3362	017	0	1	01	01	H3362_017_0	7	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H3362	017	0	1	01	01	H3362_017_0	7	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3362	017	0	1	01	01	H3362_017_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3362	017	0	1	01	01	H3362_017_0	7	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00	1	2	10001000
H3362	017	0	1	01	01	H3362_017_0	7	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H3362	017	0	1	01	01	H3362_017_0	7	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00											85.00			
H3362	017	0	1	01	01	H3362_017_0	7	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			10.00								4.00			
H3362	017	0	1	01	01	H3362_017_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			112.50								45.00			
H3362	020	0	1	01	01	H3362_020_0	5	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3362	020	0	1	01	01	H3362_020_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3362	020	0	1	01	01	H3362_020_0	5	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00	1	2	10001000
H3362	020	0	1	01	01	H3362_020_0	5	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	25									25											25	Specialty Tier 4																								
H3362	020	0	1	01	01	H3362_020_0	5	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	50.00	150.00								50.00											50.00			
H3362	020	0	1	01	01	H3362_020_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 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	5	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00			
H3362	020	0	1	01	01	H3362_020_0	5	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H3370	001	0	1	01	01	H3370_001_0	14	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3370	001	0	1	01	01	H3370_001_0	14	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	001	0	1	01	01	H3370_001_0	14	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	001	0	1	01	01	H3370_001_0	14	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3370	001	0	1	01	01	H3370_001_0	14	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3370	001	0	1	01	01	H3370_001_0	14	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3370	001	0	1	01	01	H3370_001_0	14	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	001	0	1	01	01	H3370_001_0	14	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	001	0	1	01	01	H3370_001_0	14	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	001	0	1	01	01	H3370_001_0	14	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3370	002	0	1	01	01	H3370_002_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	002	0	1	01	01	H3370_002_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3370	002	0	1	01	01	H3370_002_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	002	0	1	01	01	H3370_002_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	002	0	1	01	01	H3370_002_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3370	002	0	1	01	01	H3370_002_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	002	0	1	01	01	H3370_002_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	002	0	1	01	01	H3370_002_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3370	002	0	1	01	01	H3370_002_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3370	002	0	1	01	01	H3370_002_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3370	003	0	1	01	01	H3370_003_0	11	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3370	003	0	1	01	01	H3370_003_0	11	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	003	0	1	01	01	H3370_003_0	11	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3370	003	0	1	01	01	H3370_003_0	11	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	003	0	1	01	01	H3370_003_0	11	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3370	003	0	1	01	01	H3370_003_0	11	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3370	003	0	1	01	01	H3370_003_0	11	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	003	0	1	01	01	H3370_003_0	11	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	003	0	1	01	01	H3370_003_0	11	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3370	003	0	1	01	01	H3370_003_0	11	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	004	0	1	01	01	H3370_004_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	004	0	1	01	01	H3370_004_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3370	004	0	1	01	01	H3370_004_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	004	0	1	01	01	H3370_004_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	004	0	1	01	01	H3370_004_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3370	004	0	1	01	01	H3370_004_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	004	0	1	01	01	H3370_004_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3370	004	0	1	01	01	H3370_004_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3370	004	0	1	01	01	H3370_004_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3370	004	0	1	01	01	H3370_004_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	014	0	1	01	01	H3370_014_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3370	014	0	1	01	01	H3370_014_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00			
H3370	014	0	1	01	01	H3370_014_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	014	0	1	01	01	H3370_014_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3370	014	0	1	01	01	H3370_014_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	014	0	1	01	01	H3370_014_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	014	0	1	01	01	H3370_014_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	014	0	1	01	01	H3370_014_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						14.00			21.00		7.00	1	1	
H3370	014	0	1	01	01	H3370_014_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	014	0	1	01	01	H3370_014_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3370	021	0	1	01	01	H3370_021_0	12	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	021	0	1	01	01	H3370_021_0	12	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						160.00			240.00		80.00			
H3370	021	0	1	01	01	H3370_021_0	12	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						84.00			126.00		42.00			
H3370	021	0	1	01	01	H3370_021_0	12	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	0.00	0.00								0.00						0.00			0.00		0.00			
H3370	021	0	1	01	01	H3370_021_0	12	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	021	0	1	01	01	H3370_021_0	12	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	021	0	1	01	01	H3370_021_0	12	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3370	021	0	1	01	01	H3370_021_0	12	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	021	0	1	01	01	H3370_021_0	12	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	021	0	1	01	01	H3370_021_0	12	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	0.00	0.00								0.00						0.00			0.00		0.00	1	1	
H3370	022	0	1	01	01	H3370_022_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	5.00	15.00								5.00						10.00			15.00		5.00			
H3370	022	0	1	01	01	H3370_022_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	36.00	108.00								36.00						72.00			108.00		36.00			
H3370	022	0	1	01	01	H3370_022_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	75.00	225.00								75.00						150.00			225.00		75.00			
H3370	022	0	1	01	01	H3370_022_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3370	022	0	1	01	01	H3370_022_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3370	022	0	1	01	01	H3370_022_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3370	022	0	1	01	01	H3370_022_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3370	022	0	1	01	01	H3370_022_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	5.00	15.00								5.00						10.00			15.00		5.00	1	1	
H3370	022	0	1	01	01	H3370_022_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3370	022	0	1	01	01	H3370_022_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3379	001	0	1	01	01	H3379_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3379	001	0	1	01	01	H3379_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3379	001	0	1	01	01	H3379_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3379	001	0	1	01	01	H3379_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3379	005	0	1	01	01	H3379_005_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3379	005	0	1	01	01	H3379_005_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3379	005	0	1	01	01	H3379_005_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3379	005	0	1	01	01	H3379_005_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3379	037	0	1	01	01	H3379_037_0	5	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						230.00			240.00		80.00			
H3379	037	0	1	01	01	H3379_037_0	5	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3379	037	0	1	01	01	H3379_037_0	5	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						14.00			21.00		7.00			
H3379	037	0	1	01	01	H3379_037_0	5	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3384	013	0	1	01	01	H3384_013_0	12	3	4	1	Non-Preferred Brand/Generic	100100	1	2	2	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand/Generic	1	Non-Preferred Brand/Generic	50	50								50		50	42								50	Non-Preferred Brand/Generic																								
H3384	013	0	1	01	01	H3384_013_0	12	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	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	12	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	7.50	22.50								7.50		7.50	18.75								7.50			
H3384	013	0	1	01	01	H3384_013_0	12	1	4	3	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	7.50	22.50								7.50		7.50	18.75								7.50	1	2	00001000
H3384	013	0	1	01	01	H3384_013_0	12	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3384	013	0	1	01	01	H3384_013_0	12	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																						2		
H3384	013	0	1	01	01	H3384_013_0	12	4	4	3	Specialty Injectables	101000	1	1	1	Specialty Injectables																								Specialty Injectables		Specialty Injectables																						Specialty Injectables																						2		
H3384	013	0	1	01	01	H3384_013_0	12	4	4	1	Specialty Injectables	101000	1	1	1	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	1	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H3384	019	0	1	01	01	H3384_019_0	10	1	4	3	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	2	00001000
H3384	019	0	1	01	01	H3384_019_0	10	2	4	3	Preferred Brand	000001	1	2	2																																																																							2		
H3384	019	0	1	01	01	H3384_019_0	10	3	4	3	Non-Preferred	100100	1	2	1																																																																							2		
H3384	019	0	1	01	01	H3384_019_0	10	4	4	3	Specialty Injectables	100001	1	1	2																																																																							2		
H3384	019	0	1	01	01	H3384_019_0	10	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H3384	019	0	1	01	01	H3384_019_0	10	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H3384	019	0	1	01	01	H3384_019_0	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	42								50	Non-Preferred																								
H3384	019	0	1	01	01	H3384_019_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00			
H3384	041	0	1	01	01	H3384_041_0	12	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H3384	041	0	1	01	01	H3384_041_0	12	1	4	3	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	2	00001000
H3384	041	0	1	01	01	H3384_041_0	12	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3384	041	0	1	01	01	H3384_041_0	12	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H3384	041	0	1	01	01	H3384_041_0	12	4	4	3	Specialty Injectables	100001	1	1	2	Specialty Injectables																								Specialty Injectables		Specialty Injectables																						Specialty Injectables																						2		
H3384	041	0	1	01	01	H3384_041_0	12	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H3384	041	0	1	01	01	H3384_041_0	12	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	42								50	Non-Preferred																								
H3384	041	0	1	01	01	H3384_041_0	12	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00			
H3384	052	0	1	01	01	H3384_052_0	10	4	4	3	Specialty Injectables	100001	1	1	2	Specialty Injectables																								Specialty Injectables		Specialty Injectables																						Specialty Injectables																						2		
H3384	052	0	1	01	01	H3384_052_0	10	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H3384	052	0	1	01	01	H3384_052_0	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3384	052	0	1	01	01	H3384_052_0	10	1	4	3	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	2	00001000
H3384	052	0	1	01	01	H3384_052_0	10	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H3384	052	0	1	01	01	H3384_052_0	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	42								50	Non-Preferred																								
H3384	052	0	1	01	01	H3384_052_0	10	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H3384	052	0	1	01	01	H3384_052_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00			
H3384	053	0	1	01	01	H3384_053_0	11	3	4	1	Non-Preferred Brand/Generic	100100	1	2	2	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand/Generic	1	Non-Preferred Brand/Generic	50	50								50		50	42								50	Non-Preferred Brand/Generic																								
H3384	053	0	1	01	01	H3384_053_0	11	4	4	1	Specialty Injectables	100001	1	1	1	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	1	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H3384	053	0	1	01	01	H3384_053_0	11	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	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	11	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00			
H3388	002	0	1	01	01	H3388_002_0	7	5	4	1	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty	100010010010100000000				30			30			30		30									31		Tier 5 Formulary Specialty	1	Tier 5 Formulary Specialty				30			30			30		30									30	Tier 5 Formulary Specialty																								
H3388	002	0	1	01	01	H3388_002_0	7	4	4	1	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4 Formulary Non-Preferred Brand	2	Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand				70.00	210.00		75.00	225.00		75.00		70.00	140.00								75.00			
H3388	002	0	1	01	01	H3388_002_0	7	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2	2	Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3 Formulary Preferred Brand	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				35.00	105.00		40.00	120.00		40.00		35.00	70.00								40.00			
H3388	002	0	1	01	01	H3388_002_0	7	2	4	1	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred 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	7	1	4	1	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred 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	7	1	4	3	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00	1	1	
H3388	002	0	1	01	01	H3388_002_0	7	5	4	3	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty																								Tier 5 Formulary Specialty		Tier 5 Formulary Specialty																						Tier 5 Formulary Specialty																						2		
H3388	002	0	1	01	01	H3388_002_0	7	4	4	3	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand																								Tier 4 Formulary Non-Preferred Brand		Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand																						2		
H3388	002	0	1	01	01	H3388_002_0	7	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																						2		
H3388	002	0	1	01	01	H3388_002_0	7	2	4	3	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00	1	1	
H3388	004	0	1	01	01	H3388_004_0	6	4	4	1	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4 Formulary Non-Preferred Brand	2	Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand				70.00	210.00		75.00	225.00		75.00		70.00	140.00								75.00			
H3388	004	0	1	01	01	H3388_004_0	6	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2	2	Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3 Formulary Preferred Brand	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				35.00	105.00		40.00	120.00		40.00		35.00	70.00								40.00			
H3388	004	0	1	01	01	H3388_004_0	6	2	4	1	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred 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	6	1	4	1	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred 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	6	5	4	1	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty	100010010010100000000				30			30			30		30									31		Tier 5 Formulary Specialty	1	Tier 5 Formulary Specialty				25			25			25		25									25	Tier 5 Formulary Specialty																								
H3404	001	0	1	04	01	H3404_001_0	12	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00			
H3404	001	0	1	04	01	H3404_001_0	12	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00	70.00							35.00					35.00	87.50	70.00	35.00	105.00	70.00	35.00			
H3404	001	0	1	04	01	H3404_001_0	12	3	4	1	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 3 - Non-preferred	2	Tier 3 - Non-preferred																						Tier 3 - Non-preferred	75.00	225.00	150.00							75.00					75.00	187.50	150.00	75.00	225.00	150.00	75.00			
H3404	001	0	1	04	01	H3404_001_0	12	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 4 - Specialty	1	Tier 4 - Specialty	33	33	33							33					33	33	33	33	33	33	33	Tier 4 - Specialty																								
H3404	001	0	1	04	01	H3404_001_0	12	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00	1	1	
H3404	001	0	1	04	01	H3404_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																						2		
H3404	001	0	1	04	01	H3404_001_0	12	3	4	3	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred																								Tier 3 - Non-preferred		Tier 3 - Non-preferred																						Tier 3 - Non-preferred																						2		
H3404	001	0	1	04	01	H3404_001_0	12	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
H3404	002	0	1	04	01	H3404_002_0	13	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
H3404	002	0	1	04	01	H3404_002_0	13	3	4	3	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred																								Tier 3 - Non-preferred		Tier 3 - Non-preferred																						Tier 3 - Non-preferred																						2		
H3404	002	0	1	04	01	H3404_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																						2		
H3404	002	0	1	04	01	H3404_002_0	13	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00	1	1	
H3404	002	0	1	04	01	H3404_002_0	13	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 4 - Specialty	1	Tier 4 - Specialty	33	33	33							33					33	33	33	33	33	33	33	Tier 4 - Specialty																								
H3404	002	0	1	04	01	H3404_002_0	13	3	4	1	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 3 - Non-preferred	2	Tier 3 - Non-preferred																						Tier 3 - Non-preferred	75.00	225.00	150.00							75.00					75.00	187.50	150.00	75.00	225.00	150.00	75.00			
H3404	002	0	1	04	01	H3404_002_0	13	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00			
H3404	002	0	1	04	01	H3404_002_0	13	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00	70.00							35.00					35.00	87.50	70.00	35.00	105.00	70.00	35.00			
H3405	001	0	1	04	01	H3405_001_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3405	001	0	1	04	01	H3405_001_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3405	001	0	1	04	01	H3405_001_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H3405	001	0	1	04	01	H3405_001_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H3405	001	0	1	04	01	H3405_001_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3405	001	0	1	04	01	H3405_001_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3405	001	0	1	04	01	H3405_001_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H3405	001	0	1	04	01	H3405_001_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H3405	002	0	1	04	01	H3405_002_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3405	002	0	1	04	01	H3405_002_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3405	002	0	1	04	01	H3405_002_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H3405	002	0	1	04	01	H3405_002_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3405	002	0	1	04	01	H3405_002_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3405	002	0	1	04	01	H3405_002_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3405	002	0	1	04	01	H3405_002_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H3405	002	0	1	04	01	H3405_002_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3405	005	0	1	04	01	H3405_005_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H3405	005	0	1	04	01	H3405_005_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3405	005	0	1	04	01	H3405_005_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3405	005	0	1	04	01	H3405_005_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H3405	005	0	1	04	01	H3405_005_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H3405	005	0	1	04	01	H3405_005_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3405	005	0	1	04	01	H3405_005_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3405	005	0	1	04	01	H3405_005_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H3435	001	0	1	37	05	H3435_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3435	001	0	1	37	05	H3435_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H3435	001	0	1	37	05	H3435_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H3435	001	0	1	37	05	H3435_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3435	003	0	1	37	05	H3435_003_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H3435	003	0	1	37	05	H3435_003_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3435	003	0	1	37	05	H3435_003_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H3435	003	0	1	37	05	H3435_003_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3449	005	0	1	01	01	H3449_005_0	8	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
H3449	005	0	1	01	01	H3449_005_0	8	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00			
H3449	005	0	1	01	01	H3449_005_0	8	3	4	1	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 3 - Non-preferred	2	Tier 3 - Non-preferred																						Tier 3 - Non-preferred	75.00	225.00	150.00							75.00					75.00	187.50	150.00	75.00	225.00	150.00	75.00			
H3449	005	0	1	01	01	H3449_005_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00	70.00							35.00					35.00	87.50	70.00	35.00	105.00	70.00	35.00			
H3449	005	0	1	01	01	H3449_005_0	8	3	4	3	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred																								Tier 3 - Non-preferred		Tier 3 - Non-preferred																						Tier 3 - Non-preferred																						2		
H3449	005	0	1	01	01	H3449_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																						2		
H3449	005	0	1	01	01	H3449_005_0	8	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00	1	1	
H3449	005	0	1	01	01	H3449_005_0	8	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 4 - Specialty	1	Tier 4 - Specialty	33	33	33							33					33	33	33	33	33	33	33	Tier 4 - Specialty																								
H3449	013	0	1	01	01	H3449_013_0	10	1	4	1	Tier 1 - Generics	010000	1	2	2	Tier 1 - Generics	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generics	2	Tier 1 - Generics																						Tier 1 - Generics	7.00	21.00	14.00							7.00					0.00	0.00	0.00	7.00	21.00	14.00	7.00			
H3449	013	0	1	01	01	H3449_013_0	10	2	4	1	Tier 2 - Preferred brand	000001	1	2	2	Tier 2 - Preferred brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 2 - Preferred brand	2	Tier 2 - Preferred brand																						Tier 2 - Preferred brand	40.00	120.00	80.00							40.00					40.00	100.00	80.00	40.00	120.00	80.00	40.00			
H3449	013	0	1	01	01	H3449_013_0	10	3	4	1	Tier 3 - Non-preferred brand	100000	1	2	1	Tier 3 - Non-preferred brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 3 - Non-preferred brand	2	Tier 3 - Non-preferred brand																						Tier 3 - Non-preferred brand	80.00	240.00	160.00							80.00					80.00	200.00	160.00	80.00	240.00	160.00	80.00			
H3449	013	0	1	01	01	H3449_013_0	10	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 4 - Specialty	1	Tier 4 - Specialty	33	33	33							33					33	33	33	33	33	33	33	Tier 4 - Specialty																								
H3456	001	0	1	02	01	H3456_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3456	001	0	1	02	01	H3456_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3456	001	0	1	02	01	H3456_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3456	001	0	1	02	01	H3456_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H3456	022	0	1	01	01	H3456_022_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3456	022	0	1	01	01	H3456_022_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3456	022	0	1	01	01	H3456_022_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3456	022	0	1	01	01	H3456_022_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3456	023	0	1	02	01	H3456_023_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3456	023	0	1	02	01	H3456_023_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3456	023	0	1	02	01	H3456_023_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3456	023	0	1	02	01	H3456_023_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H3456	024	0	1	01	01	H3456_024_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3456	024	0	1	01	01	H3456_024_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3456	024	0	1	01	01	H3456_024_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3456	024	0	1	01	01	H3456_024_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3518	001	0	1	09	04	H3518_001_0	7	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	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			
H3518	001	0	1	09	04	H3518_001_0	7	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	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			
H3518	001	0	1	09	04	H3518_001_0	7	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
H3518	001	0	1	09	04	H3518_001_0	7	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
H3528	001	0	1	01	01	H3528_001_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H3528	001	0	1	01	01	H3528_001_0	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3				80.00	160.00	160.00	80.00	240.00	160.00	80.00		80.00	160.00	160.00							80.00			
H3528	001	0	1	01	01	H3528_001_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2				40.00	80.00	80.00	40.00	120.00	80.00	40.00		40.00	80.00	80.00							40.00			
H3528	001	0	1	01	01	H3528_001_0	6	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1				10.00	20.00	20.00	10.00	30.00	20.00	10.00		10.00	20.00	20.00							10.00			
H3528	002	0	1	01	01	H3528_002_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3528	002	0	1	01	01	H3528_002_0	6	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3528	002	0	1	01	01	H3528_002_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3528	002	0	1	01	01	H3528_002_0	6	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1				10.00	20.00	20.00	10.00	30.00	20.00	10.00		10.00	20.00	20.00							10.00	1	1	
H3528	002	0	1	01	01	H3528_002_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 4	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	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3				80.00	160.00	160.00	80.00	240.00	160.00	80.00		80.00	160.00	160.00							80.00			
H3528	002	0	1	01	01	H3528_002_0	6	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1				10.00	20.00	20.00	10.00	30.00	20.00	10.00		10.00	20.00	20.00							10.00			
H3528	002	0	1	01	01	H3528_002_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2				40.00	80.00	80.00	40.00	120.00	80.00	40.00		40.00	80.00	80.00							40.00			
H3528	005	0	1	01	01	H3528_005_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 4	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	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3				80.00	160.00	160.00	80.00	240.00	160.00	80.00		80.00	160.00	160.00							80.00			
H3528	005	0	1	01	01	H3528_005_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2				40.00	80.00	80.00	40.00	120.00	80.00	40.00		40.00	80.00	80.00							40.00			
H3528	005	0	1	01	01	H3528_005_0	6	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1				10.00	20.00	20.00	10.00	30.00	20.00	10.00		10.00	20.00	20.00							10.00			
H3528	006	0	1	02	01	H3528_006_0	6	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3528	006	0	1	02	01	H3528_006_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3528	006	0	1	02	01	H3528_006_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3528	006	0	1	02	01	H3528_006_0	6	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1				10.00	20.00	20.00	10.00	30.00	20.00	10.00		10.00	20.00	20.00							10.00	1	1	
H3528	006	0	1	02	01	H3528_006_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 4	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	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3				80.00	160.00	160.00	80.00	240.00	160.00	80.00		80.00	160.00	160.00							80.00			
H3528	006	0	1	02	01	H3528_006_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2				40.00	80.00	80.00	40.00	120.00	80.00	40.00		40.00	80.00	80.00							40.00			
H3528	006	0	1	02	01	H3528_006_0	6	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1				10.00	20.00	20.00	10.00	30.00	20.00	10.00		10.00	20.00	20.00							10.00			
H3533	001	0	1	01	01	H3533_001_0	9	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H3533	001	0	1	01	01	H3533_001_0	9	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H3533	001	0	1	01	01	H3533_001_0	9	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	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 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H3533	001	0	1	01	01	H3533_001_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H3533	001	0	1	01	01	H3533_001_0	9	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H3533	001	0	1	01	01	H3533_001_0	9	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3533	001	0	1	01	01	H3533_001_0	9	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H3533	001	0	1	01	01	H3533_001_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3533	001	0	1	01	01	H3533_001_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																						2		
H3597	001	0	1	01	01	H3597_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H3597	001	0	1	01	01	H3597_001_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3597	001	0	1	01	01	H3597_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	9.00	27.00									9.00					18.00			27.00		9.00			
H3597	001	0	1	01	01	H3597_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3597	001	0	1	01	01	H3597_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H3597	002	0	1	01	01	H3597_002_0	9	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H3597	002	0	1	01	01	H3597_002_0	9	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H3597	002	0	1	01	01	H3597_002_0	9	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3597	002	0	1	01	01	H3597_002_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H3597	002	0	1	01	01	H3597_002_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3597	002	0	1	01	01	H3597_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																						2		
H3597	002	0	1	01	01	H3597_002_0	9	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3597	002	0	1	01	01	H3597_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																						2		
H3597	002	0	1	01	01	H3597_002_0	9	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3597	002	0	1	01	01	H3597_002_0	9	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H3619	001	0	1	04	01	H3619_001_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	001	0	1	04	01	H3619_001_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	001	0	1	04	01	H3619_001_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H3619	001	0	1	04	01	H3619_001_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	001	0	1	04	01	H3619_001_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	001	0	1	04	01	H3619_001_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	004	0	1	04	01	H3619_004_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	004	0	1	04	01	H3619_004_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H3619	004	0	1	04	01	H3619_004_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	004	0	1	04	01	H3619_004_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	004	0	1	04	01	H3619_004_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	004	0	1	04	01	H3619_004_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H3619	004	0	1	04	01	H3619_004_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	012	0	1	04	01	H3619_012_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H3619	012	0	1	04	01	H3619_012_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	012	0	1	04	01	H3619_012_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	012	0	1	04	01	H3619_012_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	012	0	1	04	01	H3619_012_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H3619	012	0	1	04	01	H3619_012_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	012	0	1	04	01	H3619_012_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	012	0	1	04	01	H3619_012_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3619	013	0	1	04	01	H3619_013_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	013	0	1	04	01	H3619_013_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	013	0	1	04	01	H3619_013_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	013	0	1	04	01	H3619_013_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H3619	013	0	1	04	01	H3619_013_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	013	0	1	04	01	H3619_013_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	013	0	1	04	01	H3619_013_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3619	013	0	1	04	01	H3619_013_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H3619	014	0	1	04	01	H3619_014_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3619	014	0	1	04	01	H3619_014_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	014	0	1	04	01	H3619_014_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	014	0	1	04	01	H3619_014_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H3619	014	0	1	04	01	H3619_014_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	014	0	1	04	01	H3619_014_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	014	0	1	04	01	H3619_014_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	014	0	1	04	01	H3619_014_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H3619	015	0	1	04	01	H3619_015_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	015	0	1	04	01	H3619_015_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	015	0	1	04	01	H3619_015_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	015	0	1	04	01	H3619_015_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H3619	015	0	1	04	01	H3619_015_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	015	0	1	04	01	H3619_015_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	015	0	1	04	01	H3619_015_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H3619	015	0	1	04	01	H3619_015_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3619	016	0	1	04	01	H3619_016_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	016	0	1	04	01	H3619_016_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3619	016	0	1	04	01	H3619_016_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	016	0	1	04	01	H3619_016_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H3619	016	0	1	04	01	H3619_016_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	016	0	1	04	01	H3619_016_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	016	0	1	04	01	H3619_016_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3619	016	0	1	04	01	H3619_016_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H3619	017	0	1	04	01	H3619_017_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H3619	017	0	1	04	01	H3619_017_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H3619	017	0	1	04	01	H3619_017_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H3619	017	0	1	04	01	H3619_017_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H3619	017	0	1	04	01	H3619_017_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H3619	017	0	1	04	01	H3619_017_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H3619	017	0	1	04	01	H3619_017_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H3619	017	0	1	04	01	H3619_017_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H3620	001	0	1	04	01	H3620_001_0	3	4	4	1	Specialty	000010	1	1	2	Specialty	110100000010001000000	30		60							30				60							31	1	Specialty	1	Specialty	25		25							25				25							25	Specialty																								
H3620	001	0	1	04	01	H3620_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	110100000010001000000	30		60							30				60							31	1	Non-Preferred Brand	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	3	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	110100000010001000000	30		60							30				60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00			
H3620	001	0	1	04	01	H3620_001_0	3	1	4	1	Generic	010000	1	2	2	Generic	110100000010001000000	30		60							30				60							31	1	Generic	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00			
H3623	001	0	1	01	01	H3623_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3623	001	0	1	01	01	H3623_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	33.00	99.00									33.00					66.00			99.00		33.00			
H3623	001	0	1	01	01	H3623_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H3623	001	0	1	01	01	H3623_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H3623	001	0	1	01	01	H3623_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3623	003	0	1	01	01	H3623_003_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	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	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00			
H3623	003	0	1	01	01	H3623_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H3623	003	0	1	01	01	H3623_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H3623	003	0	1	01	01	H3623_003_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					56.00			84.00		28.00			
H3623	004	0	1	01	01	H3623_004_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H3623	004	0	1	01	01	H3623_004_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3623	004	0	1	01	01	H3623_004_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H3623	004	0	1	01	01	H3623_004_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H3623	004	0	1	01	01	H3623_004_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3623	006	0	1	01	01	H3623_006_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H3623	006	0	1	01	01	H3623_006_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H3623	006	0	1	01	01	H3623_006_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H3623	006	0	1	01	01	H3623_006_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H3623	006	0	1	01	01	H3623_006_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H3653	004	0	1	01	01	H3653_004_0	6	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Generic	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	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	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	6	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Brand	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	6	4	4	1	Tier 4 - Multisource Brand and Isomerics	000010	1	2	2	Tier 4 - Multisource Brand and Isomerics	110000000010000000000	30									30											31		Tier 4 - Multisource Brand and Isomerics	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	6	5	4	1	Tier 5 - Part D Eligible Injectables	010010	1	2	2	Tier 5 - Part D Eligible Injectables	110000000010000000000	30									30											31		Tier 5 - Part D Eligible Injectables	1	Tier 5 - Part D Eligible Injectables	33									33											33	Tier 5 - Part D Eligible Injectables																								
H3653	004	0	1	01	01	H3653_004_0	6	6	4	1	Tier 6 - Specialty Drugs	010010	1	1	2	Tier 6 - Specialty Drugs	110000000010000000000	30									30											31		Tier 6 - Specialty Drugs	1	Tier 6 - Specialty Drugs	33									33											33	Tier 6 - Specialty Drugs																								
H3653	015	0	1	01	01	H3653_015_0	5	2	4	1	Tier 2 - Brand	000010	1	2	1	Tier 2 - Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Brand	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	5	3	4	1	Tier 3 - Part D Eligible Injectables	010010	1	2	2	Tier 3 - Part D Eligible Injectables	110000000010000000000	30									30											31		Tier 3 - Part D Eligible Injectables	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	5	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H3653	015	0	1	01	01	H3653_015_0	5	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	10.00	30.00								10.00			20.00								10.00			
H3655	013	0	1	01	01	H3655_013_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H3655	013	0	1	01	01	H3655_013_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H3655	013	0	1	01	01	H3655_013_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H3655	013	0	1	01	01	H3655_013_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3655	013	0	1	01	01	H3655_013_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H3655	013	0	1	01	01	H3655_013_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H3655	013	0	1	01	01	H3655_013_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3655	013	0	1	01	01	H3655_013_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3655	013	0	1	01	01	H3655_013_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H3655	013	0	1	01	01	H3655_013_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3655	030	0	1	01	01	H3655_030_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H3655	030	0	1	01	01	H3655_030_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H3655	030	0	1	01	01	H3655_030_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H3655	030	0	1	01	01	H3655_030_0	9	4	4	1	Tier 4 Non-Specialty Injectible Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectible Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectible Drugs	1	Tier 4 Non-Specialty Injectible Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectible Drugs																								
H3655	030	0	1	01	01	H3655_030_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3655	030	0	1	01	01	H3655_030_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3655	030	0	1	01	01	H3655_030_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3655	030	0	1	01	01	H3655_030_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H3655	030	0	1	01	01	H3655_030_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3655	030	0	1	01	01	H3655_030_0	9	4	4	3	Tier 4 Non-Specialty Injectible Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectible Drugs																								Tier 4 Non-Specialty Injectible Drugs		Tier 4 Non-Specialty Injectible Drugs																						Tier 4 Non-Specialty Injectible Drugs																						2		
H3655	031	0	1	01	01	H3655_031_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H3655	031	0	1	01	01	H3655_031_0	9	4	4	3	Tier 4 Non-Specialty Injectible Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectible Drugs																								Tier 4 Non-Specialty Injectible Drugs		Tier 4 Non-Specialty Injectible Drugs																						Tier 4 Non-Specialty Injectible Drugs																						2		
H3655	031	0	1	01	01	H3655_031_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H3655	031	0	1	01	01	H3655_031_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H3655	031	0	1	01	01	H3655_031_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	0.00	0.00								0.00						0.00			0.00		0.00	1	1	
H3655	031	0	1	01	01	H3655_031_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H3655	031	0	1	01	01	H3655_031_0	9	4	4	1	Tier 4 Non-Specialty Injectible Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectible Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectible Drugs	1	Tier 4 Non-Specialty Injectible Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectible Drugs																								
H3655	031	0	1	01	01	H3655_031_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H3655	031	0	1	01	01	H3655_031_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	0.00	0.00								0.00						0.00			0.00		0.00			
H3655	031	0	1	01	01	H3655_031_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H3659	001	0	1	02	01	H3659_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3659	001	0	1	02	01	H3659_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3659	001	0	1	02	01	H3659_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3659	001	0	1	02	01	H3659_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3659	003	0	1	01	01	H3659_003_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3659	003	0	1	01	01	H3659_003_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3659	003	0	1	01	01	H3659_003_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H3659	003	0	1	01	01	H3659_003_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H3659	003	0	1	01	01	H3659_003_0	6	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H3659	003	0	1	01	01	H3659_003_0	6	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H3659	003	0	1	01	01	H3659_003_0	6	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H3659	003	0	1	01	01	H3659_003_0	6	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00	1	1	
H3659	031	0	1	01	01	H3659_031_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3659	031	0	1	01	01	H3659_031_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H3659	031	0	1	01	01	H3659_031_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H3659	031	0	1	01	01	H3659_031_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3659	059	0	1	01	01	H3659_059_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3659	059	0	1	01	01	H3659_059_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3659	059	0	1	01	01	H3659_059_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3660	028	0	1	02	01	H3660_028_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	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	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	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	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3660	028	0	1	02	01	H3660_028_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
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																						2		
H3660	028	0	1	02	01	H3660_028_0	7	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00	1	1	
H3660	028	0	1	02	01	H3660_028_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3660	029	0	1	02	01	H3660_029_0	7	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00	1	1	
H3660	029	0	1	02	01	H3660_029_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3660	029	0	1	02	01	H3660_029_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
H3660	029	0	1	02	01	H3660_029_0	7	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3660	029	0	1	02	01	H3660_029_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00			
H3660	029	0	1	02	01	H3660_029_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3660	029	0	1	02	01	H3660_029_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3660	029	0	1	02	01	H3660_029_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	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	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
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																						2		
H3660	032	0	1	02	01	H3660_032_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3660	032	0	1	02	01	H3660_032_0	7	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00	1	1	
H3660	032	0	1	02	01	H3660_032_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3660	032	0	1	02	01	H3660_032_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
H3660	032	0	1	02	01	H3660_032_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00			
H3660	032	0	1	02	01	H3660_032_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			7.50								3.00			
H3664	012	0	1	02	01	H3664_012_0	2	1	4	1	Generic	010000	1	2	2	Generic	110100000010001000000	30		60							30				60							31	1	Generic	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00			
H3664	012	0	1	02	01	H3664_012_0	2	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	110100000010001000000	30		60							30				60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00			
H3664	012	0	1	02	01	H3664_012_0	2	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	110100000010001000000	30		60							30				60							31	1	Non-Preferred Brand	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	2	4	4	1	Specialty	000010	1	1	2	Specialty	110100000010001000000	30		60							30				60							31	1	Specialty	1	Specialty	25		25							25				25							25	Specialty																								
H3664	012	0	1	02	01	H3664_012_0	2	1	4	3	Generic	010000	1	2	2	Generic	110100000010001000000	30		60							30				60							31	1	Generic	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00	1	1	
H3664	012	0	1	02	01	H3664_012_0	2	4	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3664	012	0	1	02	01	H3664_012_0	2	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3664	012	0	1	02	01	H3664_012_0	2	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3664	017	0	1	02	01	H3664_017_0	2	4	4	1	Specialty	000010	1	1	2	Specialty	110100000010001000000	30		60							30				60							31	1	Specialty	1	Specialty	25		25							25				25							25	Specialty																								
H3664	017	0	1	02	01	H3664_017_0	2	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	110100000010001000000	30		60							30				60							31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00		90.00							45.00				90.00							45.00			
H3664	017	0	1	02	01	H3664_017_0	2	1	4	1	Generic	010000	1	2	2	Generic	110100000010001000000	30		60							30				60							31	1	Generic	2	Generic																						Generic	4.00		8.00							4.00				8.00							4.00			
H3664	017	0	1	02	01	H3664_017_0	2	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	110100000010001000000	30		60							30				60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00		50.00							25.00				50.00							25.00			
H3668	005	0	1	01	01	H3668_005_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	50.00								25.00			
H3668	005	0	1	01	01	H3668_005_0	4	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3668	005	0	1	01	01	H3668_005_0	4	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3668	005	0	1	01	01	H3668_005_0	4	2	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H3668	005	0	1	01	01	H3668_005_0	4	1	4	3	Value Generic	001000	1	2	2	Value Generic	111000000010110000000	30	90								30		30	90								31	1	Value Generic	2	Value Generic																						Value Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H3668	005	0	1	01	01	H3668_005_0	4	5	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3668	005	0	1	01	01	H3668_005_0	4	1	4	1	Value Generic	001000	1	2	2	Value Generic	111000000010110000000	30	90								30		30	90								31	1	Value Generic	2	Value Generic																						Value Generic	5.00	15.00								5.00		5.00	10.00								5.00			
H3668	005	0	1	01	01	H3668_005_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H3668	005	0	1	01	01	H3668_005_0	4	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H3668	005	0	1	01	01	H3668_005_0	4	5	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	1	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H3668	011	0	1	01	01	H3668_011_0	4	5	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	1	Specialty Drugs	1	Specialty Drugs	25	25								25		25	25								25	Specialty Drugs																								
H3668	011	0	1	01	01	H3668_011_0	4	1	4	1	Value Generics	001000	1	2	2	Value Generics	111000000010110000000	30	90								30		30	90								31	1	Value Generics	2	Value Generics																						Value Generics	10.00	30.00								10.00		10.00	20.00								10.00			
H3668	011	0	1	01	01	H3668_011_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00		15.00	30.00								15.00			
H3668	011	0	1	01	01	H3668_011_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H3668	011	0	1	01	01	H3668_011_0	4	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00		75.00	150.00								75.00			
H3672	013	0	1	01	01	H3672_013_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H3672	013	0	1	01	01	H3672_013_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H3672	013	0	1	01	01	H3672_013_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																								
H3672	013	0	1	01	01	H3672_013_0	3	4	4	3	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	2	Specialty																						Specialty	10.00									10.00		10.00									10.00	1	2	01000000
H3672	013	0	1	01	01	H3672_013_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H3672	013	0	1	01	01	H3672_013_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3672	013	0	1	01	01	H3672_013_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3672	013	0	1	01	01	H3672_013_0	3	4	4	1	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	20									20		20									20	Specialty																								
H3706	001	0	1	01	01	H3706_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H3706	001	0	1	01	01	H3706_001_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H3706	001	0	1	01	01	H3706_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H3706	001	0	1	01	01	H3706_001_0	5	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3706	006	0	1	01	01	H3706_006_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H3706	006	0	1	01	01	H3706_006_0	4	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3706	006	0	1	01	01	H3706_006_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H3706	006	0	1	01	01	H3706_006_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H3706	017	0	1	01	01	H3706_017_0	5	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3706	017	0	1	01	01	H3706_017_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3706	017	0	1	01	01	H3706_017_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H3706	017	0	1	01	01	H3706_017_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H3706	017	0	1	01	01	H3706_017_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H3706	017	0	1	01	01	H3706_017_0	5	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H3706	017	0	1	01	01	H3706_017_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00	1	1	
H3706	017	0	1	01	01	H3706_017_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00	1	2	10000000
H3709	001	0	1	04	01	H3709_001_0	6	5	3	1	Specialty drugs	010010		1	2	Specialty drugs	111000000010110000000	30	90								30		30	90								31	1	Specialty drugs	1	Specialty drugs	30	30								30		30	30								30	Specialty drugs																								
H3709	001	0	1	04	01	H3709_001_0	6	4	3	1	Non-specialty injectables	010010		2	2	Non-specialty injectables	111000000010110000000	30	90								30		30	90								31	1	Non-specialty injectables	1	Non-specialty injectables	30	30								30		30	30								30	Non-specialty injectables																								
H3709	001	0	1	04	01	H3709_001_0	6	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	24.00								8.00			
H3709	001	0	1	04	01	H3709_001_0	6	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00		34.00	102.00								34.00			
H3709	001	0	1	04	01	H3709_001_0	6	3	3	1	Non-Preferred Brand and Non-Preferred Generic	100100		2	1	Non-Preferred Brand and Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand and Non-Preferred Generic	2	Non-Preferred Brand and Non-Preferred Generic																						Non-Preferred Brand and Non-Preferred Generic	64.00	192.00								64.00		64.00	192.00								64.00			
H3749	001	0	1	01	01	H3749_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																						2		
H3749	001	0	1	01	01	H3749_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3749	001	0	1	01	01	H3749_001_0	4	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00	1	1	
H3749	001	0	1	01	01	H3749_001_0	4	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H3749	001	0	1	01	01	H3749_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3749	001	0	1	01	01	H3749_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H3749	001	0	1	01	01	H3749_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H3749	001	0	1	01	01	H3749_001_0	4	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H3749	004	0	1	01	01	H3749_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H3749	004	0	1	01	01	H3749_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H3749	004	0	1	01	01	H3749_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3749	004	0	1	01	01	H3749_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3749	014	0	1	01	01	H3749_014_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3749	014	0	1	01	01	H3749_014_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3749	014	0	1	01	01	H3749_014_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3749	014	0	1	01	01	H3749_014_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3749	016	0	1	01	01	H3749_016_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3749	016	0	1	01	01	H3749_016_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3749	016	0	1	01	01	H3749_016_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3749	016	0	1	01	01	H3749_016_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3749	017	0	1	01	01	H3749_017_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3749	017	0	1	01	01	H3749_017_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H3749	017	0	1	01	01	H3749_017_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H3749	017	0	1	01	01	H3749_017_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3755	001	0	1	01	01	H3755_001_0	7	6	4	1	Specialty Drugs	111111	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	33	33								33		33	33								33	Specialty Drugs																								
H3755	001	0	1	01	01	H3755_001_0	7	5	4	1	Non-Specialty Injectables	111111	1	2	2	Non-Specialty Injectables	111000000010110000000	30	90								30		30	90								31	1	Non-Specialty Injectables	1	Non-Specialty Injectables	33	33								33		33	33								33	Non-Specialty Injectables																								
H3755	001	0	1	01	01	H3755_001_0	7	1	4	1	Select Generics	001000	1	2	2	Select Generics	111000000010110000000	30	90								30		30	90								31	1	Select Generics	2	Select Generics																						Select Generics	0.00	0.00								0.00		0.00	0.00								0.00			
H3755	001	0	1	01	01	H3755_001_0	7	2	4	1	Preferred Generics	001000	1	2	2	Preferred Generics	111000000010110000000	30	90								30		30	90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	7.00	21.00								7.00		7.00	21.00								7.00			
H3755	001	0	1	01	01	H3755_001_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	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	7	4	4	1	Non-Preferred Drugs	110110	1	2	1	Non-Preferred Drugs	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Drugs	2	Non-Preferred Drugs																						Non-Preferred Drugs	90.00	270.00								90.00		90.00	270.00								90.00			
H3755	004	0	1	01	01	H3755_004_0	6	1	4	1	Select Generics	001000	1	2	2	Select Generics	111000000010110000000	30	90								30		30	90								31	1	Select Generics	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	6	5	4	1	Non-Specialty Injectables	111111	1	2	2	Non-Specialty Injectables	111000000010110000000	30	90								30		30	90								31	1	Non-Specialty Injectables	1	Non-Specialty Injectables	33	33								33		33	33								33	Non-Specialty Injectables																								
H3755	004	0	1	01	01	H3755_004_0	6	4	4	1	Non-Preferred Drugs	110110	1	2	1	Non-Preferred Drugs	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Drugs	2	Non-Preferred Drugs																						Non-Preferred Drugs	90.00	270.00								90.00		90.00	270.00								90.00			
H3755	004	0	1	01	01	H3755_004_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	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	6	2	4	1	Preferred Generics	001000	1	2	2	Preferred Generics	111000000010110000000	30	90								30		30	90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	7.00	21.00								7.00		7.00	21.00								7.00			
H3755	004	0	1	01	01	H3755_004_0	6	6	4	1	Specialty Drugs	111111	1	1	2	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	33	33								33		33	33								33	Specialty Drugs																								
H3805	001	0	1	01	01	H3805_001_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H3805	001	0	1	01	01	H3805_001_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H3805	001	0	1	01	01	H3805_001_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3805	007	0	1	01	01	H3805_007_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3805	007	0	1	01	01	H3805_007_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H3805	007	0	1	01	01	H3805_007_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H3805	007	0	1	01	01	H3805_007_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3810	003	0	1	01	01	H3810_003_0	8	4	4	1	Specialty	100000	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	2	Specialty	1	Specialty				33	33		33	33		33		33	33								33	Specialty																								
H3810	003	0	1	01	01	H3810_003_0	8	3	4	1	Non-preferred Brand	100000	1	2	1	Non-preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand				69.00	138.00		69.00	207.00		69.00		69.00	138.00								69.00			
H3810	003	0	1	01	01	H3810_003_0	8	2	4	1	Brand	000011	1	2	2	Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Brand	2	Brand																						Brand				39.00	78.00		39.00	117.00		39.00		39.00	78.00								39.00			
H3810	003	0	1	01	01	H3810_003_0	8	1	4	1	Generic	011100	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00		5.00	10.00								5.00			
H3810	005	0	1	02	01	H3810_005_0	7	1	4	1	Generic	011100	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00		5.00	10.00								5.00			
H3810	005	0	1	02	01	H3810_005_0	7	2	4	1	Brand	000011	1	2	2	Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Brand	2	Brand																						Brand				39.00	78.00		39.00	117.00		39.00		39.00	78.00								39.00			
H3810	005	0	1	02	01	H3810_005_0	7	3	4	1	Non-preferred Brand	100000	1	2	1	Non-preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand				69.00	138.00		69.00	207.00		69.00		69.00	138.00								69.00			
H3810	005	0	1	02	01	H3810_005_0	7	4	4	1	Specialty	100000	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	2	Specialty	1	Specialty				33	33		33	33		33		33	33								33	Specialty																								
H3810	007	0	1	01	01	H3810_007_0	7	2	4	1	Brand	000011	1	2	2	Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Brand	2	Brand																						Brand				39.00	78.00		39.00	117.00		39.00		39.00	78.00								39.00			
H3810	007	0	1	01	01	H3810_007_0	7	4	4	1	Specialty	100000	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	2	Specialty	1	Specialty				33	33		33	33		33		33	33								33	Specialty																								
H3810	007	0	1	01	01	H3810_007_0	7	3	4	1	Non-preferred Brand	100000	1	2	1	Non-preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand				69.00	138.00		69.00	207.00		69.00		69.00	138.00								69.00			
H3810	007	0	1	01	01	H3810_007_0	7	1	4	1	Generic	011100	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00		5.00	10.00								5.00			
H3810	010	0	1	01	01	H3810_010_0	6	1	4	1	Generic	011100	1	2	2	Generic	100011011010110000000				30	90		30	90		30		30	90								31	2	Generic	2	Generic																						Generic				5.00	10.00		5.00	15.00		5.00		5.00	10.00								5.00			
H3810	010	0	1	01	01	H3810_010_0	6	4	4	1	Specialty	100000	1	1	2	Specialty	100011011010110000000				30	90		30	90		30		30	90								31	2	Specialty	1	Specialty				33	33		33	33		33		33	33								33	Specialty																								
H3810	010	0	1	01	01	H3810_010_0	6	2	4	1	Brand	000011	1	2	2	Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Brand	2	Brand																						Brand				39.00	78.00		39.00	117.00		39.00		39.00	78.00								39.00			
H3810	010	0	1	01	01	H3810_010_0	6	3	4	1	Non-preferred Brand	100000	1	2	1	Non-preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	2	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand				69.00	138.00		69.00	207.00		69.00		69.00	138.00								69.00			
H3811	002	0	1	01	01	H3811_002_0	4	5	3	1	Non-Preferred Brands Tier	100000		2	1	Non-Preferred Brands Tier	111000000010010000000	34	90								34			90								31	2	Non-Preferred Brands Tier	2	Non-Preferred Brands Tier																						Non-Preferred Brands Tier	80.00	240.00								80.00			240.00								80.00			
H3811	002	0	1	01	01	H3811_002_0	4	2	3	1	Generic Tier	010000		2	2	Generic Tier	111000000010010000000	34	90								34			90								31	2	Generic Tier	2	Generic Tier																						Generic Tier	9.00	27.00								9.00			27.00								9.00			
H3811	002	0	1	01	01	H3811_002_0	4	3	3	1	Preferred Brands Tier	000001		2	2	Preferred Brands Tier	111000000010010000000	34	90								34			90								31	2	Preferred Brands Tier	2	Preferred Brands Tier																						Preferred Brands Tier	40.00	120.00								40.00			120.00								40.00			
H3811	002	0	1	01	01	H3811_002_0	4	4	3	1	Specialty Tier	000010		1	2	Specialty Tier	110000000010000000000	34									34											31		Specialty Tier	1	Specialty Tier	30									30											30	Specialty Tier																								
H3811	002	0	1	01	01	H3811_002_0	4	1	3	1	Therapeutic Tier	010000		2	2	Therapeutic Tier	111000000010010000000	34	90								34			90								31	1	Therapeutic Tier	2	Therapeutic Tier																						Therapeutic Tier	0.00	0.00								0.00			0.00								0.00			
H3811	009	0	1	01	01	H3811_009_0	4	1	4	1	Therapeutic Tier	010000	1	2	2	Therapeutic Tier	111000000010010000000	34	90								34			90								31	1	Therapeutic Tier	2	Therapeutic Tier																						Therapeutic Tier	0.00	0.00								0.00			0.00								0.00			
H3811	009	0	1	01	01	H3811_009_0	4	2	4	1	Generic Tier	010000	1	2	2	Generic Tier	111000000010010000000	34	90								34			90								31	2	Generic Tier	2	Generic Tier																						Generic Tier	9.00	27.00								9.00			27.00								9.00			
H3811	009	0	1	01	01	H3811_009_0	4	3	4	1	Preferred Brands Tier	000001	1	2	2	Preferred Brands Tier	111000000010010000000	34	90								34			90								31	2	Preferred Brands Tier	2	Preferred Brands Tier																						Preferred Brands Tier	40.00	120.00								40.00			120.00								40.00			
H3811	009	0	1	01	01	H3811_009_0	4	4	4	1	Specialty Tier	000010	1	1	2	Specialty Tier	110000000010000000000	34									34											31		Specialty Tier	1	Specialty Tier	30									30											30	Specialty Tier																								
H3811	009	0	1	01	01	H3811_009_0	4	5	4	1	Non-Preferred Brands Tier	100000	1	2	1	Non-Preferred Brands Tier	111000000010010000000	34	90								34			90								31	2	Non-Preferred Brands Tier	2	Non-Preferred Brands Tier																						Non-Preferred Brands Tier	80.00	240.00								80.00			240.00								80.00			
H3811	009	0	1	01	01	H3811_009_0	4	1	4	3	Therapeutic Tier	010000	1	2	2	Therapeutic Tier	111000000010010000000	34	90								34			90								31	1	Therapeutic Tier	2	Therapeutic Tier																						Therapeutic Tier	0.00	0.00								0.00			0.00								0.00	1	1	
H3811	009	0	1	01	01	H3811_009_0	4	2	4	3	Generic Tier	010000	1	2	2	Generic Tier	111000000010010000000	34	90								34			90								31	2	Generic Tier	2	Generic Tier																						Generic Tier	9.00	27.00								9.00			27.00								9.00	1	1	
H3811	009	0	1	01	01	H3811_009_0	4	3	4	3	Preferred Brands Tier	000001	1	2	2	Preferred Brands Tier																								Preferred Brands Tier		Preferred Brands Tier																						Preferred Brands Tier																						2		
H3811	009	0	1	01	01	H3811_009_0	4	4	4	3	Specialty Tier	000010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H3811	009	0	1	01	01	H3811_009_0	4	5	4	3	Non-Preferred Brands Tier	100000	1	2	1	Non-Preferred Brands Tier																								Non-Preferred Brands Tier		Non-Preferred Brands Tier																						Non-Preferred Brands Tier																						2		
H3812	001	0	1	04	01	H3812_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3812	001	0	1	04	01	H3812_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H3812	001	0	1	04	01	H3812_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H3812	001	0	1	04	01	H3812_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3812	007	0	1	04	01	H3812_007_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3812	007	0	1	04	01	H3812_007_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3812	007	0	1	04	01	H3812_007_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3812	007	0	1	04	01	H3812_007_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H3813	003	0	1	04	01	H3813_003_0	9	3	4	3	Specialty Tier	000010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H3813	003	0	1	04	01	H3813_003_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	1	Generic	25	25								25		25	25								25	Generic																						1	1	
H3814	006	0	1	01	01	H3814_006_0	6	2	2	1	TIER 2 - PREFERRED BRAND	000001		2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	31.00	93.00								31.00		31.00	62.00								31.00			
H3814	006	0	1	01	01	H3814_006_0	6	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	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	6	1	2	1	TIER 1 - GENERICS	010000		2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	006	0	1	01	01	H3814_006_0	6	4	2	1	TIER 4 - SPECIALTY	100000		1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	012	0	1	01	01	H3814_012_0	6	4	2	1	TIER 4 - SPECIALTY	100000		1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	012	0	1	01	01	H3814_012_0	6	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	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	6	2	2	1	TIER 2 - PREFERRED BRAND	000001		2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	31.00	93.00								31.00		31.00	62.00								31.00			
H3814	012	0	1	01	01	H3814_012_0	6	1	2	1	TIER 1 - GENERICS	010000		2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	015	0	1	02	01	H3814_015_0	7	4	4	1	TIER 4 - SPECIALTY	100000	1	1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	015	0	1	02	01	H3814_015_0	7	3	4	1	TIER 3 - NON-PREFERRED BRAND	100000	1	2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	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	7	2	4	1	TIER 2 - PREFERRED BRAND	000001	1	2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	25.00	75.00								25.00		25.00	50.00								25.00			
H3814	015	0	1	02	01	H3814_015_0	7	1	4	1	TIER 1 - GENERICS	010000	1	2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	019	0	1	01	01	H3814_019_0	6	1	2	1	TIER 1 - GENERICS	010000		2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	019	0	1	01	01	H3814_019_0	6	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	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	6	4	2	1	TIER 4 - SPECIALTY	100000		1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	019	0	1	01	01	H3814_019_0	6	2	2	1	TIER 2 - PREFERRED BRAND	000001		2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	31.00	93.00								31.00		31.00	62.00								31.00			
H3814	021	0	1	02	01	H3814_021_0	7	3	4	1	TIER 3 - NON-PREFERRED BRAND	100000	1	2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	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	7	4	4	1	TIER 4 - SPECIALTY	100000	1	1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	021	0	1	02	01	H3814_021_0	7	2	4	1	TIER 2 - PREFERRED BRAND	000001	1	2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	25.00	75.00								25.00		25.00	50.00								25.00			
H3814	021	0	1	02	01	H3814_021_0	7	1	4	1	TIER 1 - GENERICS	010000	1	2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	024	0	1	01	01	H3814_024_0	6	4	2	1	TIER 4 - SPECIALTY	100000		1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	024	0	1	01	01	H3814_024_0	6	3	2	1	TIER 3 - NON-PREFERRED BRAND	100000		2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	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	6	1	2	1	TIER 1 - GENERICS	010000		2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	024	0	1	01	01	H3814_024_0	6	2	2	1	TIER 2 - PREFERRED BRAND	000001		2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	31.00	93.00								31.00		31.00	62.00								31.00			
H3814	025	0	1	01	01	H3814_025_0	13	3	4	1	TIER 3 - SPECIALTY	100000	1	1	2	TIER 3 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - SPECIALTY	1	TIER 3 - SPECIALTY	25	25								25		25	25								25	TIER 3 - SPECIALTY																								
H3814	025	0	1	01	01	H3814_025_0	13	1	4	1	TIER 1 - GENERICS	010000	1	2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	0.00	0.00								0.00		0.00	0.00								0.00			
H3814	025	0	1	01	01	H3814_025_0	13	2	4	1	TIER 2 - BRAND	000011	1	2	1	TIER 2 - BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - BRAND	1	TIER 2 - BRAND	25	25								25		25	25								25	TIER 2 - BRAND																								
H3814	026	0	1	02	01	H3814_026_0	7	2	4	1	TIER 2 - PREFERRED BRAND	000001	1	2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	31.00	93.00								31.00		31.00	62.00								31.00			
H3814	026	0	1	02	01	H3814_026_0	7	3	4	1	TIER 3 - NON-PREFERRED BRAND	100000	1	2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00			
H3814	026	0	1	02	01	H3814_026_0	7	4	4	1	TIER 4 - SPECIALTY	100000	1	1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	026	0	1	02	01	H3814_026_0	7	1	4	1	TIER 1 - GENERICS	010000	1	2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3814	027	0	1	02	01	H3814_027_0	7	4	4	1	TIER 4 - SPECIALTY	100000	1	1	2	TIER 4 - SPECIALTY	111000000010110000000	31	90								31		31	90								31	1	TIER 4 - SPECIALTY	1	TIER 4 - SPECIALTY	25	25								25		25	25								25	TIER 4 - SPECIALTY																								
H3814	027	0	1	02	01	H3814_027_0	7	3	4	1	TIER 3 - NON-PREFERRED BRAND	100000	1	2	2	TIER 3 - NON-PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 3 - NON-PREFERRED BRAND	2	TIER 3 - NON-PREFERRED BRAND																						TIER 3 - NON-PREFERRED BRAND	50.00	150.00								50.00		50.00	100.00								50.00			
H3814	027	0	1	02	01	H3814_027_0	7	2	4	1	TIER 2 - PREFERRED BRAND	000001	1	2	1	TIER 2 - PREFERRED BRAND	111000000010110000000	31	90								31		31	90								31	1	TIER 2 - PREFERRED BRAND	2	TIER 2 - PREFERRED BRAND																						TIER 2 - PREFERRED BRAND	31.00	93.00								31.00		31.00	62.00								31.00			
H3814	027	0	1	02	01	H3814_027_0	7	1	4	1	TIER 1 - GENERICS	010000	1	2	2	TIER 1 - GENERICS	111000000010110000000	31	90								31		31	90								31	1	TIER 1 - GENERICS	2	TIER 1 - GENERICS																						TIER 1 - GENERICS	4.00	12.00								4.00		4.00	8.00								4.00			
H3815	001	0	1	01	01	H3815_001_0	6	2	4	3	Formulary Preferred Brand Tier 2	000001	1	2	2	Formulary Preferred Brand Tier 2																								Formulary Preferred Brand Tier 2		Formulary Preferred Brand Tier 2																						Formulary Preferred Brand Tier 2																						2		
H3815	001	0	1	01	01	H3815_001_0	6	3	4	3	Formulary Non-Preferred Brand Tier 3	100000	1	2	1	Formulary Non-Preferred Brand Tier 3																								Formulary Non-Preferred Brand Tier 3		Formulary Non-Preferred Brand Tier 3																						Formulary Non-Preferred Brand Tier 3																						2		
H3815	001	0	1	01	01	H3815_001_0	6	4	4	3	Injectable Drugs Tier 4	100001	1	2	2	Injectable Drugs Tier 4																								Injectable Drugs Tier 4		Injectable Drugs Tier 4																						Injectable Drugs Tier 4																						2		
H3815	001	0	1	01	01	H3815_001_0	6	5	4	3	Specialty Drugs Tier 5	100001	1	1	2	Specialty Drugs Tier 5																								Specialty Drugs Tier 5		Specialty Drugs Tier 5																						Specialty Drugs Tier 5																						2		
H3815	001	0	1	01	01	H3815_001_0	6	1	4	1	Formulary Generic Tier 1	010000	1	2	2	Formulary Generic Tier 1	111000000001010000000	30	90									20		90								31	1	Formulary Generic Tier 1	2	Formulary Generic Tier 1																						Formulary Generic Tier 1	0.00	0.00									0.00		0.00								0.00			
H3815	001	0	1	01	01	H3815_001_0	6	2	4	1	Formulary Preferred Brand Tier 2	000001	1	2	2	Formulary Preferred Brand Tier 2	111000000001010000000	30	90									20		90								31	1	Formulary Preferred Brand Tier 2	2	Formulary Preferred Brand Tier 2																						Formulary Preferred Brand Tier 2	20.00	60.00									20.00		40.00								20.00			
H3815	001	0	1	01	01	H3815_001_0	6	3	4	1	Formulary Non-Preferred Brand Tier 3	100000	1	2	1	Formulary Non-Preferred Brand Tier 3	111000000001010000000	30	90									20		90								31	1	Formulary Non-Preferred Brand Tier 3	2	Formulary Non-Preferred Brand Tier 3																						Formulary Non-Preferred Brand Tier 3	40.00	120.00									40.00		80.00								40.00			
H3815	001	0	1	01	01	H3815_001_0	6	4	4	1	Injectable Drugs Tier 4	100001	1	2	2	Injectable Drugs Tier 4	111000000001010000000	30	90									20		90								31	1	Injectable Drugs Tier 4	1	Injectable Drugs Tier 4	33	33									33		33								33	Injectable Drugs Tier 4																								
H3815	001	0	1	01	01	H3815_001_0	6	5	4	1	Specialty Drugs Tier 5	100001	1	1	2	Specialty Drugs Tier 5	111000000001100000000	30	90									20	30									31	1	Specialty Drugs Tier 5	1	Specialty Drugs Tier 5	33	33									33	33									33	Specialty Drugs Tier 5																								
H3815	001	0	1	01	01	H3815_001_0	6	1	4	3	Formulary Generic Tier 1	010000	1	2	2	Formulary Generic Tier 1	111000000001010000000	30	90									20		90								31	1	Formulary Generic Tier 1	2	Formulary Generic Tier 1																						Formulary Generic Tier 1	0.00	0.00									0.00		0.00								0.00	1	1	
H3815	005	0	1	01	01	H3815_005_0	6	3	4	3	Formulary Non-Preferred Brand Tier 3	100000	1	2	1	Formulary Non-Preferred Brand Tier 3																								Formulary Non-Preferred Brand Tier 3		Formulary Non-Preferred Brand Tier 3																						Formulary Non-Preferred Brand Tier 3																						2		
H3815	005	0	1	01	01	H3815_005_0	6	4	4	3	Injectable Drugs Tier 4	100001	1	2	2	Injectable Drugs Tier 4																								Injectable Drugs Tier 4		Injectable Drugs Tier 4																						Injectable Drugs Tier 4																						2		
H3815	005	0	1	01	01	H3815_005_0	6	1	4	1	Formulary Generic Tier 1	010000	1	2	2	Formulary Generic Tier 1	111000000001010000000	30	90									20		90								31	1	Formulary Generic Tier 1	2	Formulary Generic Tier 1																						Formulary Generic Tier 1	0.00	0.00									0.00		0.00								0.00			
H3815	005	0	1	01	01	H3815_005_0	6	2	4	1	Formulary Preferred Brand Tier 2	000001	1	2	2	Formulary Preferred Brand Tier 2	111000000001010000000	30	90									20		90								31	1	Formulary Preferred Brand Tier 2	2	Formulary Preferred Brand Tier 2																						Formulary Preferred Brand Tier 2	20.00	60.00									20.00		40.00								20.00			
H3815	005	0	1	01	01	H3815_005_0	6	3	4	1	Formulary Non-Preferred Brand Tier 3	100000	1	2	1	Formulary Non-Preferred Brand Tier 3	111000000001010000000	30	90									20		90								31	1	Formulary Non-Preferred Brand Tier 3	2	Formulary Non-Preferred Brand Tier 3																						Formulary Non-Preferred Brand Tier 3	40.00	120.00									40.00		80.00								40.00			
H3815	005	0	1	01	01	H3815_005_0	6	4	4	1	Injectable Drugs Tier 4	100001	1	2	2	Injectable Drugs Tier 4	111000000001010000000	30	90									20		90								31	1	Injectable Drugs Tier 4	1	Injectable Drugs Tier 4	33	33									33		33								33	Injectable Drugs Tier 4																								
H3815	005	0	1	01	01	H3815_005_0	6	5	4	3	Specialty Drugs Tier 5	100001	1	1	2	Specialty Drugs Tier 5																								Specialty Drugs Tier 5		Specialty Drugs Tier 5																						Specialty Drugs Tier 5																						2		
H3815	005	0	1	01	01	H3815_005_0	6	2	4	3	Formulary Preferred Brand Tier 2	000001	1	2	2	Formulary Preferred Brand Tier 2																								Formulary Preferred Brand Tier 2		Formulary Preferred Brand Tier 2																						Formulary Preferred Brand Tier 2																						2		
H3815	005	0	1	01	01	H3815_005_0	6	1	4	3	Formulary Generic Tier 1	010000	1	2	2	Formulary Generic Tier 1	111000000001010000000	30	90									20		90								31	1	Formulary Generic Tier 1	2	Formulary Generic Tier 1																						Formulary Generic Tier 1	0.00	0.00									0.00		0.00								0.00	1	1	
H3815	005	0	1	01	01	H3815_005_0	6	5	4	1	Specialty Drugs Tier 5	100001	1	1	2	Specialty Drugs Tier 5	111000000001100000000	30	90									20	30									31	1	Specialty Drugs Tier 5	1	Specialty Drugs Tier 5	33	33									33	33									33	Specialty Drugs Tier 5																								
H3817	002	0	1	04	01	H3817_002_0	7	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	27									27		27									27	Miscellaneous Injectables																								
H3817	002	0	1	04	01	H3817_002_0	7	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	27									27		27									27	Specialty																								
H3817	002	0	1	04	01	H3817_002_0	7	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H3817	002	0	1	04	01	H3817_002_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H3817	002	0	1	04	01	H3817_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H3817	003	0	1	04	01	H3817_003_0	6	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
H3817	003	0	1	04	01	H3817_003_0	6	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3817	003	0	1	04	01	H3817_003_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3817	003	0	1	04	01	H3817_003_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3817	003	0	1	04	01	H3817_003_0	6	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
H3817	003	0	1	04	01	H3817_003_0	6	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
H3817	003	0	1	04	01	H3817_003_0	6	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
H3817	003	0	1	04	01	H3817_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H3817	003	0	1	04	01	H3817_003_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H3817	003	0	1	04	01	H3817_003_0	6	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H3818	001	0	1	01	01	H3818_001_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	30	30									30	30	30								30	Specialty																								
H3818	001	0	1	01	01	H3818_001_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	31	90									10	31	90								31	1	Generic	2	Generic																						Generic	7.00	21.00									7.00	7.00	14.00								7.00			
H3818	001	0	1	01	01	H3818_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00									70.00	70.00	140.00								70.00			
H3818	001	0	1	01	01	H3818_001_0	7	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Preferred Brand	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	4	3	1	Specialty	100001		1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	26	26									26	26	26								26	Specialty																								
H3818	003	0	1	01	01	H3818_003_0	7	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Preferred Brand	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	1	3	1	Generic	010000		2	2	Generic	111000000001110000000	31	90									10	31	90								31	1	Generic	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	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00									65.00	65.00	130.00								65.00			
H3818	014	0	1	01	01	H3818_014_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	30	30									30	30	30								30	Specialty																								
H3818	014	0	1	01	01	H3818_014_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	31	90									10	31	90								31	1	Generic	2	Generic																						Generic	7.00	21.00									7.00	7.00	14.00								7.00			
H3818	014	0	1	01	01	H3818_014_0	6	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00	30.00	60.00								30.00			
H3818	014	0	1	01	01	H3818_014_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00									70.00	70.00	140.00								70.00			
H3818	015	0	1	01	01	H3818_015_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	31	90									10	31	90								31	1	Generic	2	Generic																						Generic	5.00	15.00									5.00	5.00	10.00								5.00			
H3818	015	0	1	01	01	H3818_015_0	4	1	4	1	Diabetic	110001	1	2	2	Diabetic	111000000001110000000	31	90									10	31	90								31	1	Diabetic	2	Diabetic																						Diabetic	0.00	0.00									0.00	0.00	0.00								0.00			
H3818	015	0	1	01	01	H3818_015_0	4	3	4	1	Preferred Brand	001000	1	2	1	Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00	30.00	60.00								30.00			
H3818	015	0	1	01	01	H3818_015_0	4	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	90									10	31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00									60.00	60.00	120.00								60.00			
H3818	015	0	1	01	01	H3818_015_0	4	5	4	1	Specialty	100001	1	1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H3864	006	0	1	01	01	H3864_006_0	5	3	3	1	Specialty	001001		1	2	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H3864	006	0	1	01	01	H3864_006_0	5	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	31.00	62.00								31.00			62.00								31.00			
H3864	006	0	1	01	01	H3864_006_0	5	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	31	90								31			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	20.00								10.00			20.00								10.00			
H3864	007	0	1	02	01	H3864_007_0	5	4	4	1	Specialty	101101	1	1	2	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H3864	007	0	1	02	01	H3864_007_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00			
H3864	007	0	1	02	01	H3864_007_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	5	1	4	1	Generic	001100	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H3887	003	0	1	02	01	H3887_003_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3887	003	0	1	02	01	H3887_003_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3887	003	0	1	02	01	H3887_003_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3887	003	0	1	02	01	H3887_003_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H3887	005	0	1	02	01	H3887_005_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3887	005	0	1	02	01	H3887_005_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3887	005	0	1	02	01	H3887_005_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3887	005	0	1	02	01	H3887_005_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3907	006	0	1	01	01	H3907_006_0	6	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H3907	006	0	1	01	01	H3907_006_0	6	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H3907	006	0	1	01	01	H3907_006_0	6	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H3907	006	0	1	01	01	H3907_006_0	6	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H3907	020	0	1	01	01	H3907_020_0	5	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			270.00								90.00			
H3907	020	0	1	01	01	H3907_020_0	5	4	3	1	Specialty	010010		1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H3907	020	0	1	01	01	H3907_020_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	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	Generics	010000		2	2	Generics	111000000010010000000	31	90								31			90								31	1	Generics	2	Generics																						Generics	0.00	0.00								0.00			0.00								0.00			
H3907	029	0	1	01	01	H3907_029_0	5	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H3907	029	0	1	01	01	H3907_029_0	5	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H3907	029	0	1	01	01	H3907_029_0	5	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - 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	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H3907	030	0	1	01	01	H3907_030_0	6	1	3	1	Generics	010000		2	2	Generics	111000000010010000000	31	90								31			90								31	1	Generics	2	Generics																						Generics	0.00	0.00								0.00			0.00								0.00			
H3907	030	0	1	01	01	H3907_030_0	6	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H3907	030	0	1	01	01	H3907_030_0	6	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			270.00								90.00			
H3907	030	0	1	01	01	H3907_030_0	6	4	3	1	Specialty	010010		1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H3907	031	0	1	01	01	H3907_031_0	6	4	3	1	Specialty	010010		1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H3907	031	0	1	01	01	H3907_031_0	6	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			270.00								90.00			
H3907	031	0	1	01	01	H3907_031_0	6	1	3	1	Generics	010000		2	2	Generics	111000000010010000000	31	90								31			90								31	1	Generics	2	Generics																						Generics	0.00	0.00								0.00			0.00								0.00			
H3907	031	0	1	01	01	H3907_031_0	6	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H3909	001	0	1	04	01	H3909_001_0	7	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00			
H3909	001	0	1	04	01	H3909_001_0	7	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H3909	001	0	1	04	01	H3909_001_0	7	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	7	4	3	1	Specialty	110001		1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3912	008	0	1	04	01	H3912_008_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3912	008	0	1	04	01	H3912_008_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3912	008	0	1	04	01	H3912_008_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H3912	008	0	1	04	01	H3912_008_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H3916	001	0	1	04	01	H3916_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	001	0	1	04	01	H3916_001_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	001	0	1	04	01	H3916_001_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	001	0	1	04	01	H3916_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3916	002	0	1	04	01	H3916_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3916	002	0	1	04	01	H3916_002_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	002	0	1	04	01	H3916_002_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	002	0	1	04	01	H3916_002_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	005	0	1	04	01	H3916_005_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3916	005	0	1	04	01	H3916_005_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00			
H3916	005	0	1	04	01	H3916_005_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H3916	005	0	1	04	01	H3916_005_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3916	005	0	1	04	01	H3916_005_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00	1	1	
H3916	005	0	1	04	01	H3916_005_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	005	0	1	04	01	H3916_005_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3916	005	0	1	04	01	H3916_005_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3916	015	0	1	04	01	H3916_015_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	015	0	1	04	01	H3916_015_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3916	015	0	1	04	01	H3916_015_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	015	0	1	04	01	H3916_015_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	018	0	1	04	01	H3916_018_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	018	0	1	04	01	H3916_018_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	018	0	1	04	01	H3916_018_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3916	018	0	1	04	01	H3916_018_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	019	0	1	04	01	H3916_019_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3916	019	0	1	04	01	H3916_019_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	019	0	1	04	01	H3916_019_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	019	0	1	04	01	H3916_019_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	020	0	1	04	01	H3916_020_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	020	0	1	04	01	H3916_020_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3916	020	0	1	04	01	H3916_020_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	020	0	1	04	01	H3916_020_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	022	0	1	04	01	H3916_022_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	022	0	1	04	01	H3916_022_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3916	022	0	1	04	01	H3916_022_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		112.50	112.50								45.00			
H3916	022	0	1	04	01	H3916_022_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	024	0	1	04	01	H3916_024_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	024	0	1	04	01	H3916_024_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		112.50	112.50								45.00			
H3916	024	0	1	04	01	H3916_024_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3916	024	0	1	04	01	H3916_024_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	025	0	1	04	01	H3916_025_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3916	025	0	1	04	01	H3916_025_0	6	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	025	0	1	04	01	H3916_025_0	6	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3916	025	0	1	04	01	H3916_025_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3916	026	0	1	04	01	H3916_026_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H3916	026	0	1	04	01	H3916_026_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3916	026	0	1	04	01	H3916_026_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3916	026	0	1	04	01	H3916_026_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	026	0	1	04	01	H3916_026_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00	1	1	
H3916	026	0	1	04	01	H3916_026_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00			
H3916	026	0	1	04	01	H3916_026_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3916	026	0	1	04	01	H3916_026_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3916	027	0	1	04	01	H3916_027_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H3916	027	0	1	04	01	H3916_027_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3916	027	0	1	04	01	H3916_027_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3916	027	0	1	04	01	H3916_027_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3916	027	0	1	04	01	H3916_027_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3916	027	0	1	04	01	H3916_027_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00			
H3916	027	0	1	04	01	H3916_027_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00	1	1	
H3916	027	0	1	04	01	H3916_027_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3920	001	0	1	01	01	H3920_001_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3920	001	0	1	01	01	H3920_001_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	65.00	195.00								65.00						185.00			195.00		65.00			
H3920	001	0	1	01	01	H3920_001_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00			
H3920	001	0	1	01	01	H3920_001_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3921	001	0	1	04	01	H3921_001_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H3921	001	0	1	04	01	H3921_001_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H3921	001	0	1	04	01	H3921_001_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3921	001	0	1	04	01	H3921_001_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H3921	008	0	1	04	01	H3921_008_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H3921	008	0	1	04	01	H3921_008_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00			
H3921	008	0	1	04	01	H3921_008_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H3921	008	0	1	04	01	H3921_008_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
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																						2		
H3923	013	0	1	04	01	H3923_013_0	9	3	4	3	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3923	013	0	1	04	01	H3923_013_0	9	2	4	3	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3923	013	0	1	04	01	H3923_013_0	9	1	4	3	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.00	20.00								8.00			20.00								8.00	1	1	
H3923	013	0	1	04	01	H3923_013_0	9	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
H3923	013	0	1	04	01	H3923_013_0	9	3	4	1	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	225.00								90.00			225.00								90.00			
H3923	013	0	1	04	01	H3923_013_0	9	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Preferred Brand Drugs	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	1	4	1	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	8.00	20.00								8.00			20.00								8.00			
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																						2		
H3923	017	0	1	04	01	H3923_017_0	8	3	4	3	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3923	017	0	1	04	01	H3923_017_0	8	1	4	1	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	6.00	15.00								6.00			15.00								6.00			
H3923	017	0	1	04	01	H3923_017_0	8	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Preferred Brand Drugs	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	3	4	1	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	225.00								90.00			225.00								90.00			
H3923	017	0	1	04	01	H3923_017_0	8	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
H3923	017	0	1	04	01	H3923_017_0	8	1	4	3	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	6.00	15.00								6.00			15.00								6.00	1	1	
H3923	017	0	1	04	01	H3923_017_0	8	2	4	3	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3923	021	0	1	04	01	H3923_021_0	8	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
H3923	021	0	1	04	01	H3923_021_0	8	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	9.00	22.00								9.00			22.00								9.00			
H3923	021	0	1	04	01	H3923_021_0	8	2	4	1	Formulary Brand Drugs	000010	1	2	1	Formulary Brand Drugs	111000000010010000000	31	90								31			90								31	2	Formulary Brand Drugs	2	Formulary Brand Drugs																						Formulary Brand Drugs	45.00	112.00								45.00			112.00								45.00			
H3924	003	0	1	04	01	H3924_003_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3924	003	0	1	04	01	H3924_003_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3924	003	0	1	04	01	H3924_003_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3924	003	0	1	04	01	H3924_003_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3924	019	0	1	04	01	H3924_019_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3924	019	0	1	04	01	H3924_019_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3924	019	0	1	04	01	H3924_019_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3924	019	0	1	04	01	H3924_019_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3924	023	0	1	04	01	H3924_023_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3924	023	0	1	04	01	H3924_023_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3924	023	0	1	04	01	H3924_023_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3924	023	0	1	04	01	H3924_023_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3931	004	0	1	01	01	H3931_004_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3931	004	0	1	01	01	H3931_004_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3931	004	0	1	01	01	H3931_004_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3931	004	0	1	01	01	H3931_004_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H3931	058	0	1	01	01	H3931_058_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3931	058	0	1	01	01	H3931_058_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3931	058	0	1	01	01	H3931_058_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3931	058	0	1	01	01	H3931_058_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H3931	064	0	1	01	01	H3931_064_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3931	064	0	1	01	01	H3931_064_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3931	064	0	1	01	01	H3931_064_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3931	064	0	1	01	01	H3931_064_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H3931	065	0	1	01	01	H3931_065_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3931	065	0	1	01	01	H3931_065_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H3931	065	0	1	01	01	H3931_065_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				39.00	97.50		39.00	117.00			39.00					78.00			117.00		39.00			
H3931	065	0	1	01	01	H3931_065_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H3931	065	0	1	01	01	H3931_065_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3931	070	0	1	01	01	H3931_070_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3931	070	0	1	01	01	H3931_070_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3931	070	0	1	01	01	H3931_070_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3931	070	0	1	01	01	H3931_070_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H3931	070	0	1	01	01	H3931_070_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H3931	077	0	1	01	01	H3931_077_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H3931	077	0	1	01	01	H3931_077_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H3931	077	0	1	01	01	H3931_077_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H3931	077	0	1	01	01	H3931_077_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H3931	077	0	1	01	01	H3931_077_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H3931	077	0	1	01	01	H3931_077_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H3931	077	0	1	01	01	H3931_077_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H3931	077	0	1	01	01	H3931_077_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H3931	077	0	1	01	01	H3931_077_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																						2		
H3949	002	0	1	01	01	H3949_002_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H3949	002	0	1	01	01	H3949_002_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H3949	002	0	1	01	01	H3949_002_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3949	013	0	1	01	01	H3949_013_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H3949	013	0	1	01	01	H3949_013_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3949	013	0	1	01	01	H3949_013_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H3949	022	0	1	01	01	H3949_022_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H3949	022	0	1	01	01	H3949_022_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H3949	022	0	1	01	01	H3949_022_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H3949	022	0	1	01	01	H3949_022_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3949	024	0	1	01	01	H3949_024_0	2	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H3949	024	0	1	01	01	H3949_024_0	2	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H3949	024	0	1	01	01	H3949_024_0	2	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3949	024	0	1	01	01	H3949_024_0	2	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3949	024	0	1	01	01	H3949_024_0	2	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H3949	024	0	1	01	01	H3949_024_0	2	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H3949	024	0	1	01	01	H3949_024_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H3949	024	0	1	01	01	H3949_024_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H3949	024	0	1	01	01	H3949_024_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H3949	024	0	1	01	01	H3949_024_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3949	025	0	1	01	01	H3949_025_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H3949	025	0	1	01	01	H3949_025_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H3949	025	0	1	01	01	H3949_025_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H3949	025	0	1	01	01	H3949_025_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3949	025	0	1	01	01	H3949_025_0	3	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H3949	025	0	1	01	01	H3949_025_0	3	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H3949	025	0	1	01	01	H3949_025_0	3	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3949	025	0	1	01	01	H3949_025_0	3	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3949	025	0	1	01	01	H3949_025_0	3	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H3949	025	0	1	01	01	H3949_025_0	3	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H3952	020	0	1	01	01	H3952_020_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H3952	020	0	1	01	01	H3952_020_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			160.00								80.00			
H3952	020	0	1	01	01	H3952_020_0	7	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H3952	020	0	1	01	01	H3952_020_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H3952	020	0	1	01	01	H3952_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																						2		
H3952	020	0	1	01	01	H3952_020_0	7	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3952	020	0	1	01	01	H3952_020_0	7	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3952	020	0	1	01	01	H3952_020_0	7	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3952	043	0	1	01	01	H3952_043_0	9	4	3	1	Specialty	110001		1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3952	043	0	1	01	01	H3952_043_0	9	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00			
H3952	043	0	1	01	01	H3952_043_0	9	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H3952	043	0	1	01	01	H3952_043_0	9	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H3952	045	0	1	01	01	H3952_045_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3952	045	0	1	01	01	H3952_045_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3952	045	0	1	01	01	H3952_045_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3952	045	0	1	01	01	H3952_045_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H3952	045	0	1	01	01	H3952_045_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00			160.00								80.00			
H3952	045	0	1	01	01	H3952_045_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H3952	045	0	1	01	01	H3952_045_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H3952	045	0	1	01	01	H3952_045_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3952	047	0	1	01	01	H3952_047_0	7	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00			
H3952	047	0	1	01	01	H3952_047_0	7	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H3952	047	0	1	01	01	H3952_047_0	7	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H3952	047	0	1	01	01	H3952_047_0	7	4	3	1	Specialty	110001		1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H3954	021	0	1	01	01	H3954_021_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	021	0	1	01	01	H3954_021_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	021	0	1	01	01	H3954_021_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	021	0	1	01	01	H3954_021_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	024	0	1	01	01	H3954_024_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	024	0	1	01	01	H3954_024_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	024	0	1	01	01	H3954_024_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	024	0	1	01	01	H3954_024_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	027	0	1	01	01	H3954_027_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	027	0	1	01	01	H3954_027_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	027	0	1	01	01	H3954_027_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	027	0	1	01	01	H3954_027_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	033	0	1	01	01	H3954_033_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	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	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	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	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	033	0	1	01	01	H3954_033_0	5	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	039	0	1	01	01	H3954_039_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	039	0	1	01	01	H3954_039_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	039	0	1	01	01	H3954_039_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	039	0	1	01	01	H3954_039_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	042	0	1	01	01	H3954_042_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	042	0	1	01	01	H3954_042_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	042	0	1	01	01	H3954_042_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	042	0	1	01	01	H3954_042_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	045	0	1	01	01	H3954_045_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	045	0	1	01	01	H3954_045_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	045	0	1	01	01	H3954_045_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	045	0	1	01	01	H3954_045_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	051	0	1	01	01	H3954_051_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	051	0	1	01	01	H3954_051_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	051	0	1	01	01	H3954_051_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	051	0	1	01	01	H3954_051_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	057	0	1	01	01	H3954_057_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	057	0	1	01	01	H3954_057_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	057	0	1	01	01	H3954_057_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	057	0	1	01	01	H3954_057_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	060	0	1	01	01	H3954_060_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	060	0	1	01	01	H3954_060_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	060	0	1	01	01	H3954_060_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	060	0	1	01	01	H3954_060_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	063	0	1	01	01	H3954_063_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	063	0	1	01	01	H3954_063_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	063	0	1	01	01	H3954_063_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	063	0	1	01	01	H3954_063_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	091	0	1	01	01	H3954_091_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	091	0	1	01	01	H3954_091_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	091	0	1	01	01	H3954_091_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	091	0	1	01	01	H3954_091_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	097	0	1	01	01	H3954_097_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	95.00	285.00								95.00			237.50								95.00			
H3954	097	0	1	01	01	H3954_097_0	5	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
H3954	097	0	1	01	01	H3954_097_0	5	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 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	5	1	4	1	Tier 1	011100	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H3954	100	0	1	01	01	H3954_100_0	5	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	100	0	1	01	01	H3954_100_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	100	0	1	01	01	H3954_100_0	5	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	100	0	1	01	01	H3954_100_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	106	0	1	01	01	H3954_106_0	6	1	4	1	Tier 1	011100	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	106	0	1	01	01	H3954_106_0	6	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	106	0	1	01	01	H3954_106_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	106	0	1	01	01	H3954_106_0	6	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	112	0	1	01	01	H3954_112_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	112	0	1	01	01	H3954_112_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	112	0	1	01	01	H3954_112_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	112	0	1	01	01	H3954_112_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	115	0	1	01	01	H3954_115_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	115	0	1	01	01	H3954_115_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	115	0	1	01	01	H3954_115_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	115	0	1	01	01	H3954_115_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	124	0	1	01	01	H3954_124_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	124	0	1	01	01	H3954_124_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	124	0	1	01	01	H3954_124_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	124	0	1	01	01	H3954_124_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	127	0	1	01	01	H3954_127_0	4	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	127	0	1	01	01	H3954_127_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	127	0	1	01	01	H3954_127_0	4	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	127	0	1	01	01	H3954_127_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	134	0	1	01	01	H3954_134_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	134	0	1	01	01	H3954_134_0	6	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	134	0	1	01	01	H3954_134_0	6	4	4	3	Tier 4	100000	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3954	134	0	1	01	01	H3954_134_0	6	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3954	134	0	1	01	01	H3954_134_0	6	2	4	3	Tier 2	000011	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3954	134	0	1	01	01	H3954_134_0	6	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00	1	2	00001000
H3954	134	0	1	01	01	H3954_134_0	6	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	134	0	1	01	01	H3954_134_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	135	0	1	01	01	H3954_135_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H3954	135	0	1	01	01	H3954_135_0	5	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H3954	135	0	1	01	01	H3954_135_0	5	2	4	3	Tier 2	000011	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H3954	135	0	1	01	01	H3954_135_0	5	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00	1	2	00001000
H3954	135	0	1	01	01	H3954_135_0	5	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H3954	135	0	1	01	01	H3954_135_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H3954	135	0	1	01	01	H3954_135_0	5	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H3954	135	0	1	01	01	H3954_135_0	5	4	4	3	Tier 4	100000	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H3957	003	0	1	01	01	H3957_003_0	7	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3957	003	0	1	01	01	H3957_003_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3957	003	0	1	01	01	H3957_003_0	7	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3957	003	0	1	01	01	H3957_003_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3957	006	0	1	01	01	H3957_006_0	10	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3957	006	0	1	01	01	H3957_006_0	10	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3957	006	0	1	01	01	H3957_006_0	10	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3957	006	0	1	01	01	H3957_006_0	10	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3957	020	0	1	01	01	H3957_020_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3957	020	0	1	01	01	H3957_020_0	9	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H3957	020	0	1	01	01	H3957_020_0	9	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3957	020	0	1	01	01	H3957_020_0	9	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3957	020	0	1	01	01	H3957_020_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00	1	1	
H3957	020	0	1	01	01	H3957_020_0	9	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3957	020	0	1	01	01	H3957_020_0	9	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3957	020	0	1	01	01	H3957_020_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3957	021	0	1	01	01	H3957_021_0	9	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H3957	021	0	1	01	01	H3957_021_0	9	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H3957	021	0	1	01	01	H3957_021_0	9	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3957	021	0	1	01	01	H3957_021_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00	1	1	
H3957	021	0	1	01	01	H3957_021_0	9	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3957	021	0	1	01	01	H3957_021_0	9	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H3957	021	0	1	01	01	H3957_021_0	9	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H3957	021	0	1	01	01	H3957_021_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3957	031	0	1	01	01	H3957_031_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3957	031	0	1	01	01	H3957_031_0	9	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3957	031	0	1	01	01	H3957_031_0	9	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3957	031	0	1	01	01	H3957_031_0	9	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3957	032	0	1	01	01	H3957_032_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H3957	032	0	1	01	01	H3957_032_0	9	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H3957	032	0	1	01	01	H3957_032_0	9	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H3957	032	0	1	01	01	H3957_032_0	9	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H3959	001	0	1	01	01	H3959_001_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H3959	001	0	1	01	01	H3959_001_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	68.00	204.00								68.00			204.00								68.00			
H3959	001	0	1	01	01	H3959_001_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	38.00	114.00								38.00			95.00								38.00			
H3959	001	0	1	01	01	H3959_001_0	7	1	4	1	Tier 1 - Preferred Generics	001000	3	2	2	Tier 1 - Preferred Generics	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generics	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	6.00	18.00								6.00			15.00								6.00			
H3959	001	0	1	01	01	H3959_001_0	7	4	4	3	Tier 4 - Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3959	001	0	1	01	01	H3959_001_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand																								Non-Preferred Generic/Non-Preferred Brand		Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand																						2		
H3959	001	0	1	01	01	H3959_001_0	7	2	4	3	Tier 2 - Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H3959	001	0	1	01	01	H3959_001_0	7	1	4	3	Tier 1 - Preferred Generics	001000	3	2	2	Tier 1 - Preferred Generics	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generics	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	6.00	18.00								6.00			15.00								6.00	1	1	
H3959	002	0	1	01	01	H3959_002_0	8	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	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	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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	002	0	1	01	01	H3959_002_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	38.00	114.00								38.00			95.00								38.00			
H3959	002	0	1	01	01	H3959_002_0	8	1	4	1	Tier 1 - Preferred Generics	001000	3	2	2	Tier 1 - Preferred Generics	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generics	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	5.00	15.00								5.00			12.50								5.00			
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																						2		
H3959	002	0	1	01	01	H3959_002_0	8	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	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																						2		
H3959	002	0	1	01	01	H3959_002_0	8	1	4	3	Tier 1 - Preferred Generics	001000	3	2	2	Tier 1 - Preferred Generics	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generics	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	5.00	15.00								5.00			12.50								5.00	1	1	
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																						2		
H3959	010	0	1	01	01	H3959_010_0	10	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	68.00	204.00								68.00			204.00								68.00			
H3959	010	0	1	01	01	H3959_010_0	10	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H3959	010	0	1	01	01	H3959_010_0	10	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	37.00	111.00								37.00			92.50								37.00			
H3959	010	0	1	01	01	H3959_010_0	10	1	4	1	Tier 1 - Preferred Generics	001000	1	2	2	Tier 1 - Preferred Generics	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generics	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	4.00	12.00								4.00			10.00								4.00			
H3959	011	0	1	01	01	H3959_011_0	8	1	4	1	Tier 1 - Preferred Generics	001000	1	2	2	Tier 1 - Preferred Generics	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generics	2	Tier 1 - Preferred Generics																						Tier 1 - Preferred Generics	6.00	18.00								6.00			15.00								6.00			
H3959	011	0	1	01	01	H3959_011_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H3959	011	0	1	01	01	H3959_011_0	8	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	64.00	192.00								64.00			192.00								64.00			
H3959	011	0	1	01	01	H3959_011_0	8	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H3962	001	0	1	01	01	H3962_001_0	6	4	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3962	001	0	1	01	01	H3962_001_0	6	3	4	3	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3962	001	0	1	01	01	H3962_001_0	6	2	4	3	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3962	001	0	1	01	01	H3962_001_0	6	1	4	3	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	6.00	15.00								6.00			15.00								6.00	1	1	
H3962	001	0	1	01	01	H3962_001_0	6	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
H3962	001	0	1	01	01	H3962_001_0	6	3	4	1	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	225.00								90.00			225.00								90.00			
H3962	001	0	1	01	01	H3962_001_0	6	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Preferred Brand Drugs	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	6	1	4	1	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	6.00	15.00								6.00			15.00								6.00			
H3962	004	0	1	01	01	H3962_004_0	6	3	4	3	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H3962	004	0	1	01	01	H3962_004_0	6	4	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H3962	004	0	1	01	01	H3962_004_0	6	2	4	3	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H3962	004	0	1	01	01	H3962_004_0	6	1	4	3	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00	1	1	
H3962	004	0	1	01	01	H3962_004_0	6	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
H3962	004	0	1	01	01	H3962_004_0	6	3	4	1	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	225.00								90.00			225.00								90.00			
H3962	004	0	1	01	01	H3962_004_0	6	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Preferred Brand Drugs	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	6	1	4	1	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00			
H3962	007	0	1	01	01	H3962_007_0	6	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	9.00	22.00								9.00			22.00								9.00			
H3962	007	0	1	01	01	H3962_007_0	6	2	4	1	Formulary Brand Drugs	000010	1	2	1	Formulary Brand Drugs	111000000010010000000	31	90								31			90								31	2	Formulary Brand Drugs	2	Formulary Brand Drugs																						Formulary Brand Drugs	45.00	112.00								45.00			112.00								45.00			
H3962	007	0	1	01	01	H3962_007_0	6	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
H3964	002	0	1	01	01	H3964_002_0	3	1	4	1	Generic	010000	1	2	2	Generic	110000000010000000000	31									31											31		Generic	2	Generic																						Generic	0.00									0.00											0.00			
H3964	002	0	1	01	01	H3964_002_0	3	2	4	1	Preferred Brand	010011	1	2	1	Preferred Brand	110000000010000000000	31									31											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00									45.00											45.00			
H3964	003	0	1	01	01	H3964_003_0	2	1	3	1	Generic	010000		2	2	Generic	110000000010000000000	31									31											31		Generic	2	Generic																						Generic	5.00									5.00											5.00			
H3964	003	0	1	01	01	H3964_003_0	2	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	110000000010000000000	31									31											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00									40.00											40.00			
H3964	003	0	1	01	01	H3964_003_0	2	3	3	1	Specialty	010010		1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	28									28											28	Specialty																								
H4003	001	0	1	01	01	H4003_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																						2		
H4003	001	0	1	01	01	H4003_001_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4003	001	0	1	01	01	H4003_001_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4003	001	0	1	01	01	H4003_001_0	5	4	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H4003	001	0	1	01	01	H4003_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00			
H4003	001	0	1	01	01	H4003_001_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	29.00	87.00								29.00			58.00								29.00			
H4003	001	0	1	01	01	H4003_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H4003	001	0	1	01	01	H4003_001_0	5	4	4	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4003	009	0	1	01	01	H4003_009_0	6	2	4	1	Other Generics	010000	1	2	2	Other Generics	111000000010010000000	30	90								30			90								31	2	Other Generics	2	Other Generics																						Other Generics	5.00	15.00								5.00			10.00								5.00			
H4003	009	0	1	01	01	H4003_009_0	6	5	4	3	Specialty Drugs	010011	1	1	1	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H4003	009	0	1	01	01	H4003_009_0	6	4	4	3	Other Brands	000010	1	2	2	Other Brands																								Other Brands		Other Brands																						Other Brands																						2		
H4003	009	0	1	01	01	H4003_009_0	6	3	4	3	Insulins	000010	1	2	2	Insulins																								Insulins		Insulins																						Insulins																						2		
H4003	009	0	1	01	01	H4003_009_0	6	2	4	3	Other Generics	010000	1	2	2	Other Generics	111000000010010000000	30	90								30			90								31	2	Other Generics	2	Other Generics																						Other Generics	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4003	009	0	1	01	01	H4003_009_0	6	1	4	3	Generics DM, CHF, CV	010000	1	2	2	Generics DM, CHF, CV	111000000010010000000	30	90								30			90								31	2	Generics DM, CHF, CV	2	Generics DM, CHF, CV																						Generics DM, CHF, CV	3.00	9.00								3.00			6.00								3.00	1	2	00001000
H4003	009	0	1	01	01	H4003_009_0	6	5	4	1	Specialty Drugs	010011	1	1	1	Specialty Drugs	111000000010010000000	30	90								30			90								31	2	Specialty Drugs	1	Specialty Drugs	25	25								25			25								25	Specialty Drugs																								
H4003	009	0	1	01	01	H4003_009_0	6	4	4	1	Other Brands	000010	1	2	2	Other Brands	111000000010010000000	30	90								30			90								31	2	Other Brands	2	Other Brands																						Other Brands	50.00	150.00								50.00			100.00								50.00			
H4003	009	0	1	01	01	H4003_009_0	6	3	4	1	Insulins	000010	1	2	2	Insulins	111000000010010000000	30	90								30			90								31	2	Insulins	2	Insulins																						Insulins	20.00	60.00								20.00			40.00								20.00			
H4003	009	0	1	01	01	H4003_009_0	6	1	4	1	Generics DM, CHF, CV	010000	1	2	2	Generics DM, CHF, CV	111000000010010000000	30	90								30			90								31	2	Generics DM, CHF, CV	2	Generics DM, CHF, CV																						Generics DM, CHF, CV	3.00	9.00								3.00			6.00								3.00			
H4003	015	0	1	01	01	H4003_015_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	29.00	87.00								29.00			58.00								29.00			
H4003	015	0	1	01	01	H4003_015_0	5	3	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H4003	015	0	1	01	01	H4003_015_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4003	015	0	1	01	01	H4003_015_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4003	015	0	1	01	01	H4003_015_0	5	3	4	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4003	015	0	1	01	01	H4003_015_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H4003	019	0	1	01	01	H4003_019_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
H4003	019	0	1	01	01	H4003_019_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H4003	019	0	1	01	01	H4003_019_0	5	3	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4003	019	0	1	01	01	H4003_019_0	5	3	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00			
H4003	019	0	1	01	01	H4003_019_0	5	4	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H4003	019	0	1	01	01	H4003_019_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4003	019	0	1	01	01	H4003_019_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4003	019	0	1	01	01	H4003_019_0	5	4	4	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4004	015	0	1	01	01	H4004_015_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H4004	015	0	1	01	01	H4004_015_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	29.00	87.00								29.00			58.00								29.00			
H4004	015	0	1	01	01	H4004_015_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			100.00								50.00			
H4004	015	0	1	01	01	H4004_015_0	5	4	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H4004	015	0	1	01	01	H4004_015_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4004	015	0	1	01	01	H4004_015_0	5	4	4	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4004	015	0	1	01	01	H4004_015_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4004	015	0	1	01	01	H4004_015_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4004	035	0	1	01	01	H4004_035_0	5	3	4	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4004	035	0	1	01	01	H4004_035_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4004	035	0	1	01	01	H4004_035_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4004	035	0	1	01	01	H4004_035_0	5	3	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H4004	035	0	1	01	01	H4004_035_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H4004	035	0	1	01	01	H4004_035_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	29.00	87.00								29.00			58.00								29.00			
H4004	049	0	1	01	01	H4004_049_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	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	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4004	049	0	1	01	01	H4004_049_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4004	049	0	1	01	01	H4004_049_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4004	049	0	1	01	01	H4004_049_0	5	3	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	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	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	29.00	87.00								29.00			58.00								29.00			
H4004	050	0	1	01	01	H4004_050_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H4004	050	0	1	01	01	H4004_050_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
H4004	050	0	1	01	01	H4004_050_0	5	3	4	1	Specialty	010011	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H4004	050	0	1	01	01	H4004_050_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	2	00001000
H4004	050	0	1	01	01	H4004_050_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H4004	050	0	1	01	01	H4004_050_0	5	3	4	3	Specialty	010011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4005	003	0	1	04	01	H4005_003_0	4	4	4	3	Tier 4/Nivel 4	100100	1	2	1	Tier 4/Nivel 4																								Tier 4/Nivel 4		Tier 4/Nivel 4																						Tier 4/Nivel 4																						2		
H4005	003	0	1	04	01	H4005_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																						2		
H4005	003	0	1	04	01	H4005_003_0	4	2	4	3	Tier 2/Nivel 2	001001	1	2	2	Tier 2/Nivel 2																								Tier 2/Nivel 2		Tier 2/Nivel 2																						Tier 2/Nivel 2																						2		
H4005	003	0	1	04	01	H4005_003_0	4	1	4	3	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00	1	1	
H4005	003	0	1	04	01	H4005_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																						2		
H4005	003	0	1	04	01	H4005_003_0	4	4	4	1	Tier 4/Nivel 4	100100	1	2	1	Tier 4/Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/Nivel 4	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	4	3	4	1	Tier 3/Nivel 3	000010	1	2	2	Tier 3/Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/Nivel 3	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	25.00	75.00	25.00							25.00			75.00								25.00			
H4005	003	0	1	04	01	H4005_003_0	4	2	4	1	Tier 2/Nivel 2	001001	1	2	2	Tier 2/Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/Nivel 2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	15.00	45.00	15.00							15.00			45.00								15.00			
H4005	003	0	1	04	01	H4005_003_0	4	1	4	1	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 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	4	5	4	1	Tier 5/Nivel 5	010010	1	1	2	Tier 5/Nivel 5	111100000010010000000	30	90	15							30			90								31	2	Tier 5/Nivel 5	1	Tier 5/Nivel 5	25	25	25							25			25								25	Tier 5/Nivel 5																								
H4005	004	0	1	04	01	H4005_004_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																						2		
H4005	004	0	1	04	01	H4005_004_0	4	4	4	3	Tier 4/Nivel 4	100100	1	2	1	Tier 4/Nivel 4																								Tier 4/Nivel 4		Tier 4/Nivel 4																						Tier 4/Nivel 4																						2		
H4005	004	0	1	04	01	H4005_004_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																						2		
H4005	004	0	1	04	01	H4005_004_0	4	2	4	3	Tier 2/Nivel 2	001001	1	2	2	Tier 2/Nivel 2																								Tier 2/Nivel 2		Tier 2/Nivel 2																						Tier 2/Nivel 2																						2		
H4005	004	0	1	04	01	H4005_004_0	4	1	4	3	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	5.00	15.00	5.00							5.00			15.00								5.00	1	1	
H4005	004	0	1	04	01	H4005_004_0	4	5	4	1	Tier 5/Nivel 5	010010	1	1	2	Tier 5/Nivel 5	111100000010010000000	30	90	15							30			90								31	2	Tier 5/Nivel 5	1	Tier 5/Nivel 5	25	25	25							25			25								25	Tier 5/Nivel 5																								
H4005	004	0	1	04	01	H4005_004_0	4	4	4	1	Tier 4/Nivel 4	100100	1	2	1	Tier 4/Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/Nivel 4	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	4	3	4	1	Tier 3/Nivel 3	000010	1	2	2	Tier 3/Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/Nivel 3	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	45.00	135.00	45.00							45.00			135.00								45.00			
H4005	004	0	1	04	01	H4005_004_0	4	1	4	1	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 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	4	2	4	1	Tier 2/Nivel 2	001001	1	2	2	Tier 2/Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/Nivel 2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	25.00	75.00	25.00							25.00			75.00								25.00			
H4006	007	0	1	01	01	H4006_007_0	10	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4006	007	0	1	01	01	H4006_007_0	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4006	007	0	1	01	01	H4006_007_0	10	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00	1	1	
H4006	007	0	1	01	01	H4006_007_0	10	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4006	007	0	1	01	01	H4006_007_0	10	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H4006	007	0	1	01	01	H4006_007_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	24.00	72.00								24.00		24.00	48.00								24.00			
H4006	007	0	1	01	01	H4006_007_0	10	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H4006	007	0	1	01	01	H4006_007_0	10	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4006	008	0	1	02	01	H4006_008_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00	1	1	
H4006	008	0	1	02	01	H4006_008_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4006	008	0	1	02	01	H4006_008_0	9	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4006	008	0	1	02	01	H4006_008_0	9	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4006	008	0	1	02	01	H4006_008_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00			
H4006	008	0	1	02	01	H4006_008_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	40.00								20.00			
H4006	008	0	1	02	01	H4006_008_0	9	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4006	008	0	1	02	01	H4006_008_0	9	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	24.00	72.00								24.00		24.00	48.00								24.00			
H4006	020	0	1	01	01	H4006_020_0	10	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H4006	020	0	1	01	01	H4006_020_0	10	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4006	020	0	1	01	01	H4006_020_0	10	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4006	020	0	1	01	01	H4006_020_0	10	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00	1	1	
H4006	020	0	1	01	01	H4006_020_0	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4006	020	0	1	01	01	H4006_020_0	10	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4006	020	0	1	01	01	H4006_020_0	10	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	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	10	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00			
H4006	022	0	1	01	01	H4006_022_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	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	10	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	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	10	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4007	010	0	1	01	01	H4007_010_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4007	010	0	1	01	01	H4007_010_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4007	010	0	1	01	01	H4007_010_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H4007	010	0	1	01	01	H4007_010_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4007	010	0	1	01	01	H4007_010_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4007	010	0	1	01	01	H4007_010_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H4007	010	0	1	01	01	H4007_010_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4007	012	0	1	01	01	H4007_012_0	3	2	4	3	Brand	000011	1	2	2	Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Brand	2	Brand																						Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00	1	2	10000000
H4007	012	0	1	01	01	H4007_012_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Generic	2	Generic																						Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	00001000
H4007	012	0	1	01	01	H4007_012_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4007	012	0	1	01	01	H4007_012_0	3	2	4	1	Brand	000011	1	2	2	Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Brand	2	Brand																						Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00			
H4007	012	0	1	01	01	H4007_012_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Generic	2	Generic																						Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H4007	012	0	1	01	01	H4007_012_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10000000
H4008	001	0	1	09	04	H4008_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4008	001	0	1	09	04	H4008_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	15.00	45.00								15.00					15.00	37.50		15.00	45.00		15.00	1	2	10001000
H4008	001	0	1	09	04	H4008_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4008	001	0	1	09	04	H4008_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4008	001	0	1	09	04	H4008_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	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	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	35.00	105.00								35.00					35.00	87.50		35.00	105.00		35.00	1	2	10000000
H4011	003	0	1	04	01	H4011_003_0	6	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
H4011	003	0	1	04	01	H4011_003_0	6	2	4	3	2	000001	1	2	2	2																								2		2																						2																						2		
H4011	003	0	1	04	01	H4011_003_0	6	1	4	3	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00	1	1	
H4011	003	0	1	04	01	H4011_003_0	6	4	4	1	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																								
H4011	003	0	1	04	01	H4011_003_0	6	3	4	1	3	100000	1	2	1	3	111000000010000000000	30	90								30											31	2	3	2	3																						3	30.00	90.00								30.00											30.00			
H4011	003	0	1	04	01	H4011_003_0	6	2	4	1	2	000001	1	2	2	2	111000000010000000000	30	90								30											31	2	2	2	2																						2	20.00	60.00								20.00											20.00			
H4011	003	0	1	04	01	H4011_003_0	6	1	4	1	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00			
H4011	003	0	1	04	01	H4011_003_0	6	4	4	3	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																						1	2	01000000
H4011	004	0	1	04	01	H4011_004_0	6	4	4	3	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																						1	2	01000000
H4011	004	0	1	04	01	H4011_004_0	6	1	4	1	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00			
H4011	004	0	1	04	01	H4011_004_0	6	2	4	1	2	000001	1	2	2	2	111000000010000000000	30	90								30											31	2	2	2	2																						2	15.00	45.00								15.00											15.00			
H4011	004	0	1	04	01	H4011_004_0	6	3	4	1	3	100000	1	2	1	3	111000000010000000000	30	90								30											31	2	3	2	3																						3	30.00	90.00								30.00											30.00			
H4011	004	0	1	04	01	H4011_004_0	6	4	4	1	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																								
H4011	004	0	1	04	01	H4011_004_0	6	1	4	3	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00	1	1	
H4011	004	0	1	04	01	H4011_004_0	6	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
H4011	004	0	1	04	01	H4011_004_0	6	2	4	3	2	000001	1	2	2	2																								2		2																						2																						2		
H4012	004	0	1	01	01	H4012_004_0	4	4	4	3	Tier 4/Nivel 4	110000	3	1	2	Tier 4/Nivel 4																								Tier 4/Nivel 4		Tier 4/Nivel 4																						Tier 4/Nivel 4																						2		
H4012	004	0	1	01	01	H4012_004_0	4	3	4	3	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3																								Tier 3/Nivel 3		Tier 3/Nivel 3																						Tier 3/Nivel 3																						2		
H4012	004	0	1	01	01	H4012_004_0	4	2	4	3	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2																								Tier 2/Nivel 2		Tier 2/Nivel 2																						Tier 2/Nivel 2																						2		
H4012	004	0	1	01	01	H4012_004_0	4	1	4	3	Tier 1/Nivel 1	010000	3	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	1	Tier 1/Nivel 1	70	70	70							70			70								70	Tier 1/Nivel 1																						1	1	
H4012	004	0	1	01	01	H4012_004_0	4	4	4	1	Tier 4/Nivel 4	110000	3	1	2	Tier 4/Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/Nivel 4	1	Tier 4/Nivel 4	25	25	25							25			25								25	Tier 4/Nivel 4																								
H4012	004	0	1	01	01	H4012_004_0	4	3	4	1	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/Nivel 3	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	60.00	180.00	60.00							60.00			180.00								60.00			
H4012	004	0	1	01	01	H4012_004_0	4	1	4	1	Tier 1/Nivel 1	010000	3	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	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	4	2	4	1	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/Nivel 2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	25.00	75.00	25.00							25.00			75.00								25.00			
H4012	005	0	1	01	01	H4012_005_0	4	1	4	1	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	0.00	0.00	0.00							0.00			0.00								0.00			
H4012	005	0	1	01	01	H4012_005_0	4	2	4	1	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/Nivel 2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	5.00	15.00	5.00							5.00			15.00								5.00			
H4012	005	0	1	01	01	H4012_005_0	4	3	4	1	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/Nivel 3	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	15.00	45.00	15.00							15.00			45.00								15.00			
H4012	005	0	1	01	01	H4012_005_0	4	4	4	1	Tier 4/Nivel 4	010010	3	1	2	Tier 4/Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/Nivel 4	1	Tier 4/Nivel 4	25	25	25							25			25								25	Tier 4/Nivel 4																								
H4012	005	0	1	01	01	H4012_005_0	4	4	4	3	Tier 4/Nivel 4	010010	3	1	2	Tier 4/Nivel 4																								Tier 4/Nivel 4		Tier 4/Nivel 4																						Tier 4/Nivel 4																						2		
H4012	005	0	1	01	01	H4012_005_0	4	1	4	3	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	1	Tier 1/Nivel 1	70	70	70							70			70								70	Tier 1/Nivel 1																						1	1	
H4012	005	0	1	01	01	H4012_005_0	4	2	4	3	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2																								Tier 2/Nivel 2		Tier 2/Nivel 2																						Tier 2/Nivel 2																						2		
H4012	005	0	1	01	01	H4012_005_0	4	3	4	3	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3																								Tier 3/Nivel 3		Tier 3/Nivel 3																						Tier 3/Nivel 3																						2		
H4012	007	0	1	01	01	H4012_007_0	3	4	4	1	Tier 4/Nivel 4	110000	3	1	2	Tier 4/Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/Nivel 4	1	Tier 4/Nivel 4	25	25	25							25			25								25	Tier 4/Nivel 4																								
H4012	007	0	1	01	01	H4012_007_0	3	3	4	1	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/Nivel 3	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	60.00	180.00	60.00							60.00			180.00								60.00			
H4012	007	0	1	01	01	H4012_007_0	3	2	4	1	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/Nivel 2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	25.00	75.00	25.00							25.00			75.00								25.00			
H4012	007	0	1	01	01	H4012_007_0	3	1	4	1	Tier 1/Nivel 1	010000	3	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	0.00	0.00	0.00							0.00			0.00								0.00			
H4012	007	0	1	01	01	H4012_007_0	3	4	4	3	Tier 4/Nivel 4	110000	3	1	2	Tier 4/Nivel 4																								Tier 4/Nivel 4		Tier 4/Nivel 4																						Tier 4/Nivel 4																						2		
H4012	007	0	1	01	01	H4012_007_0	3	3	4	3	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3																								Tier 3/Nivel 3		Tier 3/Nivel 3																						Tier 3/Nivel 3																						2		
H4012	007	0	1	01	01	H4012_007_0	3	1	4	3	Tier 1/Nivel 1	010000	3	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	1	Tier 1/Nivel 1	70	70	70							70			70								70	Tier 1/Nivel 1																						1	1	
H4012	007	0	1	01	01	H4012_007_0	3	2	4	3	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2																								Tier 2/Nivel 2		Tier 2/Nivel 2																						Tier 2/Nivel 2																						2		
H4012	008	0	1	01	01	H4012_008_0	3	2	4	3	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2																								Tier 2/Nivel 2		Tier 2/Nivel 2																						Tier 2/Nivel 2																						2		
H4012	008	0	1	01	01	H4012_008_0	3	1	4	3	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	1	Tier 1/Nivel 1	70	70	70							70			70								70	Tier 1/Nivel 1																						1	1	
H4012	008	0	1	01	01	H4012_008_0	3	4	4	1	Tier 4/Nivel 4	010010	3	1	2	Tier 4/Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/Nivel 4	1	Tier 4/Nivel 4	25	25	25							25			25								25	Tier 4/Nivel 4																								
H4012	008	0	1	01	01	H4012_008_0	3	3	4	1	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/Nivel 3	2	Tier 3/Nivel 3																						Tier 3/Nivel 3	15.00	45.00	15.00							15.00			45.00								15.00			
H4012	008	0	1	01	01	H4012_008_0	3	2	4	1	Tier 2/Nivel 2	001001	3	2	2	Tier 2/Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/Nivel 2	2	Tier 2/Nivel 2																						Tier 2/Nivel 2	5.00	15.00	5.00							5.00			15.00								5.00			
H4012	008	0	1	01	01	H4012_008_0	3	1	4	1	Tier 1/Nivel 1	010000	1	2	2	Tier 1/Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/Nivel 1	2	Tier 1/Nivel 1																						Tier 1/Nivel 1	0.00	0.00	0.00							0.00			0.00								0.00			
H4012	008	0	1	01	01	H4012_008_0	3	3	4	3	Tier 3/Nivel 3	000010	3	2	1	Tier 3/Nivel 3																								Tier 3/Nivel 3		Tier 3/Nivel 3																						Tier 3/Nivel 3																						2		
H4012	008	0	1	01	01	H4012_008_0	3	4	4	3	Tier 4/Nivel 4	010010	3	1	2	Tier 4/Nivel 4																								Tier 4/Nivel 4		Tier 4/Nivel 4																						Tier 4/Nivel 4																						2		
H4036	001	0	1	04	01	H4036_001_0	12	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H4036	001	0	1	04	01	H4036_001_0	12	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H4036	001	0	1	04	01	H4036_001_0	12	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H4036	001	0	1	04	01	H4036_001_0	12	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H4036	001	0	1	04	01	H4036_001_0	12	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H4036	001	0	1	04	01	H4036_001_0	12	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H4036	001	0	1	04	01	H4036_001_0	12	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H4036	001	0	1	04	01	H4036_001_0	12	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H4036	001	0	1	04	01	H4036_001_0	12	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H4036	001	0	1	04	01	H4036_001_0	12	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H4036	003	0	1	04	01	H4036_003_0	11	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H4036	003	0	1	04	01	H4036_003_0	11	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H4036	003	0	1	04	01	H4036_003_0	11	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H4036	003	0	1	04	01	H4036_003_0	11	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H4036	003	0	1	04	01	H4036_003_0	11	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H4036	003	0	1	04	01	H4036_003_0	11	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H4036	003	0	1	04	01	H4036_003_0	11	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H4036	003	0	1	04	01	H4036_003_0	11	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H4036	003	0	1	04	01	H4036_003_0	11	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H4036	003	0	1	04	01	H4036_003_0	11	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H4102	001	0	1	02	01	H4102_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4102	001	0	1	02	01	H4102_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4102	001	0	1	02	01	H4102_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4102	001	0	1	02	01	H4102_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4106	002	0	1	01	01	H4106_002_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H4106	002	0	1	01	01	H4106_002_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H4106	002	0	1	01	01	H4106_002_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4106	002	0	1	01	01	H4106_002_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4125	001	0	1	01	01	H4125_001_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4125	001	0	1	01	01	H4125_001_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H4125	001	0	1	01	01	H4125_001_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																						2		
H4125	001	0	1	01	01	H4125_001_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4125	001	0	1	01	01	H4125_001_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H4125	001	0	1	01	01	H4125_001_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4125	001	0	1	01	01	H4125_001_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4125	001	0	1	01	01	H4125_001_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4125	001	0	1	01	01	H4125_001_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4125	001	0	1	01	01	H4125_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H4125	002	0	1	01	01	H4125_002_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4125	002	0	1	01	01	H4125_002_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4125	002	0	1	01	01	H4125_002_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																						2		
H4125	002	0	1	01	01	H4125_002_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4125	002	0	1	01	01	H4125_002_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H4125	002	0	1	01	01	H4125_002_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4125	002	0	1	01	01	H4125_002_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00			
H4125	002	0	1	01	01	H4125_002_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H4125	002	0	1	01	01	H4125_002_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H4125	002	0	1	01	01	H4125_002_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H4125	003	0	1	01	01	H4125_003_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4125	003	0	1	01	01	H4125_003_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4125	003	0	1	01	01	H4125_003_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																						2		
H4125	003	0	1	01	01	H4125_003_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4125	003	0	1	01	01	H4125_003_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H4125	003	0	1	01	01	H4125_003_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4125	003	0	1	01	01	H4125_003_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4125	003	0	1	01	01	H4125_003_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4125	003	0	1	01	01	H4125_003_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H4125	003	0	1	01	01	H4125_003_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H4125	006	0	1	01	01	H4125_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																						2		
H4125	006	0	1	01	01	H4125_006_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4125	006	0	1	01	01	H4125_006_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H4125	006	0	1	01	01	H4125_006_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4125	006	0	1	01	01	H4125_006_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H4125	006	0	1	01	01	H4125_006_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4125	006	0	1	01	01	H4125_006_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	10.00	30.00								10.00			20.00								10.00			
H4125	006	0	1	01	01	H4125_006_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H4125	006	0	1	01	01	H4125_006_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H4125	006	0	1	01	01	H4125_006_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4141	001	0	1	01	01	H4141_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H4141	001	0	1	01	01	H4141_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H4141	001	0	1	01	01	H4141_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4141	001	0	1	01	01	H4141_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4141	001	0	1	01	01	H4141_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	1	
H4141	001	0	1	01	01	H4141_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H4141	001	0	1	01	01	H4141_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4141	001	0	1	01	01	H4141_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4152	005	0	1	01	01	H4152_005_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010000010010	30	90								30						90			90		31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00						75.00			90.00		30.00			
H4152	005	0	1	01	01	H4152_005_0	8	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010000010010	30	90								30						90			90		31	2	Tier 4	1	Tier 4	25	25								25						25			25		25	Tier 4																								
H4152	005	0	1	01	01	H4152_005_0	8	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010000010010	30	90								30						90			90		31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00						175.00			210.00		70.00			
H4152	005	0	1	01	01	H4152_005_0	8	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						16.00			24.00		8.00			
H4152	007	0	1	02	01	H4152_007_0	8	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						16.00			24.00		8.00			
H4152	007	0	1	02	01	H4152_007_0	8	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010000010010	30	90								30						90			90		31	2	Tier 4	1	Tier 4	25	25								25						25			25		25	Tier 4																								
H4152	007	0	1	02	01	H4152_007_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010000010010	30	90								30						90			90		31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00						75.00			90.00		30.00			
H4152	007	0	1	02	01	H4152_007_0	8	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010000010010	30	90								30						90			90		31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00						175.00			210.00		70.00			
H4152	007	0	1	02	01	H4152_007_0	8	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4152	007	0	1	02	01	H4152_007_0	8	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						16.00			24.00		8.00	1	1	
H4152	007	0	1	02	01	H4152_007_0	8	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4152	007	0	1	02	01	H4152_007_0	8	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4152	013	0	1	01	01	H4152_013_0	8	4	3	1	Tier 4	010010		1	2	Tier 4	111000000010000010010	30	90								30						90			90		31	2	Tier 4	1	Tier 4	25	25								25						25			25		25	Tier 4																								
H4152	013	0	1	01	01	H4152_013_0	8	3	3	1	Tier 3	100000		2	1	Tier 3	111000000010000010010	30	90								30						90			90		31	2	Tier 3	2	Tier 3																						Tier 3	90.00	270.00								90.00						225.00			270.00		90.00			
H4152	013	0	1	01	01	H4152_013_0	8	1	3	1	Tier 1	010000		2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00						20.00			30.00		10.00			
H4152	013	0	1	01	01	H4152_013_0	8	2	3	1	Tier 2	000001		2	2	Tier 2	111000000010000010010	30	90								30						90			90		31	2	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00						95.00			114.00		38.00			
H4155	001	0	1	01	01	H4155_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H4155	001	0	1	01	01	H4155_001_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	10.00	20.00								10.00		10.00	20.00								10.00			
H4155	001	0	1	01	01	H4155_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	25.00	50.00								25.00		25.00	50.00								25.00			
H4155	001	0	1	01	01	H4155_001_0	5	4	4	1	Specialty	100000	3	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H4155	001	0	1	01	01	H4155_001_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H4155	001	0	1	01	01	H4155_001_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4155	001	0	1	01	01	H4155_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4155	001	0	1	01	01	H4155_001_0	5	4	4	3	Specialty	100000	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4155	004	0	1	01	01	H4155_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	25.00	50.00								25.00		25.00	50.00								25.00			
H4155	004	0	1	01	01	H4155_004_0	5	4	4	1	Specialty	100000	3	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H4155	004	0	1	01	01	H4155_004_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H4155	004	0	1	01	01	H4155_004_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4155	004	0	1	01	01	H4155_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4155	004	0	1	01	01	H4155_004_0	5	4	4	3	Specialty	100000	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4155	004	0	1	01	01	H4155_004_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H4155	004	0	1	01	01	H4155_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	10.00	20.00								10.00		10.00	20.00								10.00			
H4205	005	0	1	09	04	H4205_005_0	6	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	11.00	33.00								11.00						27.50			33.00		11.00			
H4205	005	0	1	09	04	H4205_005_0	6	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00			
H4205	005	0	1	09	04	H4205_005_0	6	5	4	3	Specialty	010010	1	1	1																																																																							2		
H4205	005	0	1	09	04	H4205_005_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4205	005	0	1	09	04	H4205_005_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4205	005	0	1	09	04	H4205_005_0	6	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	11.00	33.00								11.00						27.50			33.00		11.00	1	1	
H4205	005	0	1	09	04	H4205_005_0	6	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00	1	1	
H4205	005	0	1	09	04	H4205_005_0	6	5	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4205	005	0	1	09	04	H4205_005_0	6	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4205	005	0	1	09	04	H4205_005_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
H4205	006	0	1	09	04	H4205_006_0	6	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00	1	1	
H4205	006	0	1	09	04	H4205_006_0	6	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	11.00	33.00								11.00						27.50			33.00		11.00	1	1	
H4205	006	0	1	09	04	H4205_006_0	6	5	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4205	006	0	1	09	04	H4205_006_0	6	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4205	006	0	1	09	04	H4205_006_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
H4205	006	0	1	09	04	H4205_006_0	6	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	11.00	33.00								11.00						27.50			33.00		11.00			
H4205	006	0	1	09	04	H4205_006_0	6	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00			
H4205	006	0	1	09	04	H4205_006_0	6	5	4	3	Specialty	010010	1	1	1																																																																							2		
H4205	006	0	1	09	04	H4205_006_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4205	006	0	1	09	04	H4205_006_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4205	007	0	1	09	04	H4205_007_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4205	007	0	1	09	04	H4205_007_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4205	007	0	1	09	04	H4205_007_0	6	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	10.00	30.00								10.00						25.00			30.00		10.00	1	1	
H4205	007	0	1	09	04	H4205_007_0	6	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00	1	1	
H4205	007	0	1	09	04	H4205_007_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00			
H4205	007	0	1	09	04	H4205_007_0	6	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00			
H4205	007	0	1	09	04	H4205_007_0	6	5	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4205	007	0	1	09	04	H4205_007_0	6	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4205	007	0	1	09	04	H4205_007_0	6	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H4205	007	0	1	09	04	H4205_007_0	6	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	10.00	30.00								10.00						25.00			30.00		10.00			
H4205	008	0	1	09	04	H4205_008_0	6	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H4205	008	0	1	09	04	H4205_008_0	6	4	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4205	008	0	1	09	04	H4205_008_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4205	008	0	1	09	04	H4205_008_0	6	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	10.00	30.00								10.00						25.00			30.00		10.00	1	1	
H4205	008	0	1	09	04	H4205_008_0	6	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00	1	1	
H4205	008	0	1	09	04	H4205_008_0	6	5	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4205	008	0	1	09	04	H4205_008_0	6	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4205	008	0	1	09	04	H4205_008_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00						87.50			105.00		35.00			
H4205	008	0	1	09	04	H4205_008_0	6	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	3.00	9.00								3.00						6.00			9.00		3.00			
H4205	008	0	1	09	04	H4205_008_0	6	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	10.00	30.00								10.00						25.00			30.00		10.00			
H4209	001	0	1	04	01	H4209_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4209	001	0	1	04	01	H4209_001_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
H4209	001	0	1	04	01	H4209_001_0	6	1	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	10.00	30.00								10.00						25.00			30.00		10.00			
H4209	001	0	1	04	01	H4209_001_0	6	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4209	003	0	1	04	01	H4209_003_0	6	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4209	003	0	1	04	01	H4209_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4209	003	0	1	04	01	H4209_003_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
H4209	003	0	1	04	01	H4209_003_0	6	1	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	10.00	30.00								10.00						25.00			30.00		10.00			
H4209	004	0	1	04	01	H4209_004_0	6	3	4	3	Value Preferred Brand	000001	1	2	2	Value Preferred Brand																								Value Preferred Brand		Value Preferred Brand																						Value Preferred Brand																						2		
H4209	004	0	1	04	01	H4209_004_0	6	4	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4209	004	0	1	04	01	H4209_004_0	6	5	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4209	004	0	1	04	01	H4209_004_0	6	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	9.00	27.00								9.00						22.50			27.00		9.00	1	1	
H4209	004	0	1	04	01	H4209_004_0	6	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	2.00	6.00								2.00						4.00			6.00		2.00	1	1	
H4209	004	0	1	04	01	H4209_004_0	6	6	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4209	004	0	1	04	01	H4209_004_0	6	5	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4209	004	0	1	04	01	H4209_004_0	6	4	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
H4209	004	0	1	04	01	H4209_004_0	6	3	4	1	Value Preferred Brand	000001	1	2	2	Value Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Value Preferred Brand	2	Value Preferred Brand																						Value Preferred Brand	25.00	75.00								25.00						62.50			75.00		25.00			
H4209	004	0	1	04	01	H4209_004_0	6	6	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H4209	004	0	1	04	01	H4209_004_0	6	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	2.00	6.00								2.00						4.00			6.00		2.00			
H4209	004	0	1	04	01	H4209_004_0	6	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	9.00	27.00								9.00						22.50			27.00		9.00			
H4209	006	0	1	04	01	H4209_006_0	6	5	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
H4209	006	0	1	04	01	H4209_006_0	6	6	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
H4209	006	0	1	04	01	H4209_006_0	6	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	2.00	6.00								2.00						4.00			6.00		2.00	1	1	
H4209	006	0	1	04	01	H4209_006_0	6	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	9.00	27.00								9.00						22.50			27.00		9.00	1	1	
H4209	006	0	1	04	01	H4209_006_0	6	3	4	3	Value Preferred Brand	000001	1	2	2	Value Preferred Brand																								Value Preferred Brand		Value Preferred Brand																						Value Preferred Brand																						2		
H4209	006	0	1	04	01	H4209_006_0	6	4	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4209	006	0	1	04	01	H4209_006_0	6	5	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4209	006	0	1	04	01	H4209_006_0	6	6	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H4209	006	0	1	04	01	H4209_006_0	6	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	2.00	6.00								2.00						4.00			6.00		2.00			
H4209	006	0	1	04	01	H4209_006_0	6	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	9.00	27.00								9.00						22.50			27.00		9.00			
H4209	006	0	1	04	01	H4209_006_0	6	3	4	1	Value Preferred Brand	000001	1	2	2	Value Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Value Preferred Brand	2	Value Preferred Brand																						Value Preferred Brand	25.00	75.00								25.00						62.50			75.00		25.00			
H4209	006	0	1	04	01	H4209_006_0	6	4	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
H4213	004	0	1	09	04	H4213_004_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	7.00	17.50								7.00		7.00	17.50								7.00			
H4213	004	0	1	09	04	H4213_004_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
H4213	004	0	1	09	04	H4213_004_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
H4213	004	0	1	09	04	H4213_004_0	6	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4213	005	0	1	09	04	H4213_005_0	5	1	3	1	Generic	010000		2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	7.00	17.50								7.00		7.00	17.50								7.00			
H4213	005	0	1	09	04	H4213_005_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
H4213	005	0	1	09	04	H4213_005_0	5	4	3	1	Specialty	000010		1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4213	005	0	1	09	04	H4213_005_0	5	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
H4213	006	0	1	09	04	H4213_006_0	5	1	3	1	Generic	010000		2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	7.00	17.50								7.00		7.00	17.50								7.00			
H4213	006	0	1	09	04	H4213_006_0	5	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
H4213	006	0	1	09	04	H4213_006_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
H4213	006	0	1	09	04	H4213_006_0	5	4	3	1	Specialty	000010		1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4213	007	0	1	09	04	H4213_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
H4213	007	0	1	09	04	H4213_007_0	6	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4213	007	0	1	09	04	H4213_007_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	7.00	17.50								7.00		7.00	17.50								7.00			
H4213	007	0	1	09	04	H4213_007_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
H4213	008	0	1	09	04	H4213_008_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
H4213	008	0	1	09	04	H4213_008_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
H4213	008	0	1	09	04	H4213_008_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	7.00	17.50								7.00		7.00	17.50								7.00			
H4213	008	0	1	09	04	H4213_008_0	6	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H4270	002	0	1	02	01	H4270_002_0	8	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00	1	1	
H4270	002	0	1	02	01	H4270_002_0	8	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000001010000000	30	90									29		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H4270	002	0	1	02	01	H4270_002_0	8	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									29		90								31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00		120.00								60.00			
H4270	002	0	1	02	01	H4270_002_0	8	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4270	002	0	1	02	01	H4270_002_0	8	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									29		90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00		60.00								30.00			
H4270	002	0	1	02	01	H4270_002_0	8	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00			
H4270	002	0	1	02	01	H4270_002_0	8	4	4	3	Tier 4	000010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4270	002	0	1	02	01	H4270_002_0	8	3	4	3	Tier 3	000010	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4270	003	0	1	02	01	H4270_003_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									29		90								31	2	Tier 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	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000001010000000	30	90									29		90								31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00									8.00		16.00								8.00			
H4270	003	0	1	02	01	H4270_003_0	7	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									29		90								31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00		120.00								60.00			
H4270	003	0	1	02	01	H4270_003_0	7	4	4	1	Tier 4	000010	1	1	2	Tier 4	111000000001010000000	30	90									29		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H4346	001	0	1	01	01	H4346_001_0	8	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H4346	001	0	1	01	01	H4346_001_0	8	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H4346	001	0	1	01	01	H4346_001_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H4346	001	0	1	01	01	H4346_001_0	8	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00	1	1	
H4346	001	0	1	01	01	H4346_001_0	8	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H4346	001	0	1	01	01	H4346_001_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	001	0	1	01	01	H4346_001_0	8	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H4346	001	0	1	01	01	H4346_001_0	8	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H4346	001	0	1	01	01	H4346_001_0	8	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H4346	001	0	1	01	01	H4346_001_0	8	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	15.00	45.00								15.00			30.00								15.00			
H4346	001	0	1	01	01	H4346_001_0	8	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H4346	001	0	1	01	01	H4346_001_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	003	0	1	01	01	H4346_003_0	9	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H4346	003	0	1	01	01	H4346_003_0	9	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	003	0	1	01	01	H4346_003_0	9	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H4346	003	0	1	01	01	H4346_003_0	9	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	003	0	1	01	01	H4346_003_0	9	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H4346	003	0	1	01	01	H4346_003_0	9	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H4346	003	0	1	01	01	H4346_003_0	9	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	003	0	1	01	01	H4346_003_0	9	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H4346	003	0	1	01	01	H4346_003_0	9	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	003	0	1	01	01	H4346_003_0	9	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H4346	003	0	1	01	01	H4346_003_0	9	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H4346	003	0	1	01	01	H4346_003_0	9	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H4346	005	0	1	01	01	H4346_005_0	7	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H4346	005	0	1	01	01	H4346_005_0	7	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H4346	005	0	1	01	01	H4346_005_0	7	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H4346	005	0	1	01	01	H4346_005_0	7	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	005	0	1	01	01	H4346_005_0	7	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H4346	005	0	1	01	01	H4346_005_0	7	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	005	0	1	01	01	H4346_005_0	7	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H4346	005	0	1	01	01	H4346_005_0	7	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H4346	005	0	1	01	01	H4346_005_0	7	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H4346	005	0	1	01	01	H4346_005_0	7	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	005	0	1	01	01	H4346_005_0	7	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H4346	005	0	1	01	01	H4346_005_0	7	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	006	0	1	01	01	H4346_006_0	8	4	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00								35.00			70.00								35.00			
H4346	006	0	1	01	01	H4346_006_0	8	3	4	1	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	006	0	1	01	01	H4346_006_0	8	2	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00			
H4346	006	0	1	01	01	H4346_006_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00			
H4346	006	0	1	01	01	H4346_006_0	8	5	4	1	Brand Drugs	000010	1	2	1	Brand Drugs	111000000010010000000	31	93								31			93								31	1	Brand Drugs	2	Brand Drugs																						Brand Drugs	60.00	180.00								60.00			120.00								60.00			
H4346	006	0	1	01	01	H4346_006_0	8	6	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H4346	006	0	1	01	01	H4346_006_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111000000010010000000	31	93								31			93								31	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	006	0	1	01	01	H4346_006_0	8	2	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	93								31			93								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	5.00	15.00								5.00			10.00								5.00	1	1	
H4346	006	0	1	01	01	H4346_006_0	8	3	4	3	Enhanced Care Brand Drugs	000010	1	2	2	Enhanced Care Brand Drugs	111000000010010000000	31	93								31			93								31	1	Enhanced Care Brand Drugs	2	Enhanced Care Brand Drugs																						Enhanced Care Brand Drugs	0.00	0.00								0.00			0.00								0.00	1	1	
H4346	006	0	1	01	01	H4346_006_0	8	4	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H4346	006	0	1	01	01	H4346_006_0	8	5	4	3	Brand Drugs	000010	1	2	1	Brand Drugs																								Brand Drugs		Brand Drugs																						Brand Drugs																						2		
H4346	006	0	1	01	01	H4346_006_0	8	6	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111000000010010000000	31	93								31			93								31	1	Specialty Drugs	1	Specialty Drugs	33	33								33			33								33	Specialty Drugs																								
H4406	001	0	1	02	01	H4406_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4406	001	0	1	02	01	H4406_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4406	001	0	1	02	01	H4406_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						0.00			18.00		6.00			
H4406	001	0	1	02	01	H4406_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4407	001	0	1	01	01	H4407_001_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50			
H4407	001	0	1	01	01	H4407_001_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
H4407	001	0	1	01	01	H4407_001_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4407	001	0	1	01	01	H4407_001_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H4407	001	0	1	01	01	H4407_001_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4407	001	0	1	01	01	H4407_001_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50	1	1	
H4407	001	0	1	01	01	H4407_001_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50	1	1	
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																						2		
H4407	001	0	1	01	01	H4407_001_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4407	001	0	1	01	01	H4407_001_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4407	002	0	1	01	01	H4407_002_0	8	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00			45.00								15.00			
H4407	002	0	1	01	01	H4407_002_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4407	002	0	1	01	01	H4407_002_0	8	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4407	002	0	1	01	01	H4407_002_0	8	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4407	002	0	1	01	01	H4407_002_0	8	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4407	002	0	1	01	01	H4407_002_0	8	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00			45.00								15.00	1	1	
H4407	002	0	1	01	01	H4407_002_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4407	002	0	1	01	01	H4407_002_0	8	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4407	002	0	1	01	01	H4407_002_0	8	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H4407	002	0	1	01	01	H4407_002_0	8	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H4407	009	0	1	01	01	H4407_009_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50	1	2	01000000
H4407	009	0	1	01	01	H4407_009_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50	1	1	
H4407	009	0	1	01	01	H4407_009_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4407	009	0	1	01	01	H4407_009_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H4407	009	0	1	01	01	H4407_009_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4407	009	0	1	01	01	H4407_009_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50			
H4407	009	0	1	01	01	H4407_009_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
H4407	009	0	1	01	01	H4407_009_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4407	009	0	1	01	01	H4407_009_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4407	009	0	1	01	01	H4407_009_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4407	013	0	1	01	01	H4407_013_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4407	013	0	1	01	01	H4407_013_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4407	013	0	1	01	01	H4407_013_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4407	013	0	1	01	01	H4407_013_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4407	013	0	1	01	01	H4407_013_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	2	01000000
H4407	013	0	1	01	01	H4407_013_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4407	013	0	1	01	01	H4407_013_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4407	013	0	1	01	01	H4407_013_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																								
H4407	013	0	1	01	01	H4407_013_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H4407	013	0	1	01	01	H4407_013_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4407	020	0	1	01	01	H4407_020_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4407	020	0	1	01	01	H4407_020_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H4407	020	0	1	01	01	H4407_020_0	6	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00			
H4407	020	0	1	01	01	H4407_020_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H4407	020	0	1	01	01	H4407_020_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4407	020	0	1	01	01	H4407_020_0	6	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4407	020	0	1	01	01	H4407_020_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	1	
H4407	020	0	1	01	01	H4407_020_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4407	020	0	1	01	01	H4407_020_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4407	020	0	1	01	01	H4407_020_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4407	021	0	1	01	01	H4407_021_0	7	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50			
H4407	021	0	1	01	01	H4407_021_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4407	021	0	1	01	01	H4407_021_0	7	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H4407	021	0	1	01	01	H4407_021_0	7	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4407	021	0	1	01	01	H4407_021_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50	1	1	
H4407	021	0	1	01	01	H4407_021_0	7	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50	1	1	
H4407	021	0	1	01	01	H4407_021_0	7	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4407	021	0	1	01	01	H4407_021_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
H4407	021	0	1	01	01	H4407_021_0	7	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4407	021	0	1	01	01	H4407_021_0	7	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4408	001	0	1	04	01	H4408_001_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4408	001	0	1	04	01	H4408_001_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4408	001	0	1	04	01	H4408_001_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4408	001	0	1	04	01	H4408_001_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H4408	001	0	1	04	01	H4408_001_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4408	001	0	1	04	01	H4408_001_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4408	001	0	1	04	01	H4408_001_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H4408	002	0	1	04	01	H4408_002_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4408	002	0	1	04	01	H4408_002_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4408	002	0	1	04	01	H4408_002_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4408	002	0	1	04	01	H4408_002_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H4408	002	0	1	04	01	H4408_002_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4408	002	0	1	04	01	H4408_002_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4408	002	0	1	04	01	H4408_002_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H4408	006	0	1	04	01	H4408_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H4408	006	0	1	04	01	H4408_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4408	006	0	1	04	01	H4408_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4408	006	0	1	04	01	H4408_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H4408	006	0	1	04	01	H4408_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4408	006	0	1	04	01	H4408_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4408	006	0	1	04	01	H4408_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4408	007	0	1	04	01	H4408_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H4408	007	0	1	04	01	H4408_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4408	007	0	1	04	01	H4408_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4408	007	0	1	04	01	H4408_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H4408	007	0	1	04	01	H4408_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4408	007	0	1	04	01	H4408_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4408	007	0	1	04	01	H4408_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4449	013	0	1	09	04	H4449_013_0	11	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	6.00	18.00								6.00			12.00								6.00			
H4449	013	0	1	09	04	H4449_013_0	11	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4449	013	0	1	09	04	H4449_013_0	11	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	110000000010000000000	30									30											31		Non-Preferred	2	Non-Preferred																						Non-Preferred	80.00									80.00											80.00			
H4449	013	0	1	09	04	H4449_013_0	11	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			134.00								45.00			
H4449	014	0	1	09	04	H4449_014_0	11	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	110000000010000000000	30									30											31		Non-Preferred	2	Non-Preferred																						Non-Preferred	80.00									80.00											80.00			
H4449	014	0	1	09	04	H4449_014_0	11	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			80.00								40.00			
H4449	014	0	1	09	04	H4449_014_0	11	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00			
H4449	014	0	1	09	04	H4449_014_0	11	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4454	002	0	1	01	01	H4454_002_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50			
H4454	002	0	1	01	01	H4454_002_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50			
H4454	002	0	1	01	01	H4454_002_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4454	002	0	1	01	01	H4454_002_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50	1	1	
H4454	002	0	1	01	01	H4454_002_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4454	002	0	1	01	01	H4454_002_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4454	002	0	1	01	01	H4454_002_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4454	002	0	1	01	01	H4454_002_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4454	002	0	1	01	01	H4454_002_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50	1	1	
H4454	007	0	1	01	01	H4454_007_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4454	007	0	1	01	01	H4454_007_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4454	007	0	1	01	01	H4454_007_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50			
H4454	007	0	1	01	01	H4454_007_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4454	007	0	1	01	01	H4454_007_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
H4454	007	0	1	01	01	H4454_007_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4454	007	0	1	01	01	H4454_007_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.50	25.50								8.50			25.50								8.50	1	2	01000000
H4454	007	0	1	01	01	H4454_007_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50	1	1	
H4454	007	0	1	01	01	H4454_007_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4454	007	0	1	01	01	H4454_007_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H4454	019	0	1	01	01	H4454_019_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4454	019	0	1	01	01	H4454_019_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H4454	019	0	1	01	01	H4454_019_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4454	019	0	1	01	01	H4454_019_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H4454	019	0	1	01	01	H4454_019_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4454	019	0	1	01	01	H4454_019_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4454	019	0	1	01	01	H4454_019_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4454	019	0	1	01	01	H4454_019_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H4454	021	0	1	01	01	H4454_021_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50	1	1	
H4454	021	0	1	01	01	H4454_021_0	7	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50	1	1	
H4454	021	0	1	01	01	H4454_021_0	7	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4454	021	0	1	01	01	H4454_021_0	7	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4454	021	0	1	01	01	H4454_021_0	7	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4454	021	0	1	01	01	H4454_021_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4454	021	0	1	01	01	H4454_021_0	7	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50			
H4454	021	0	1	01	01	H4454_021_0	7	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4454	021	0	1	01	01	H4454_021_0	7	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50			
H4456	010	0	1	01	01	H4456_010_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4456	010	0	1	01	01	H4456_010_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4456	010	0	1	01	01	H4456_010_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4456	010	0	1	01	01	H4456_010_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	013	0	1	01	01	H4456_013_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	013	0	1	01	01	H4456_013_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4456	013	0	1	01	01	H4456_013_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4456	013	0	1	01	01	H4456_013_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4456	015	0	1	01	01	H4456_015_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	54.00	162.00								54.00						152.00			162.00		54.00			
H4456	015	0	1	01	01	H4456_015_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	24.00	72.00								24.00						62.00			72.00		24.00			
H4456	015	0	1	01	01	H4456_015_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4456	015	0	1	01	01	H4456_015_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	019	0	1	01	01	H4456_019_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						0.00			15.00		5.00			
H4456	019	0	1	01	01	H4456_019_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	019	0	1	01	01	H4456_019_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4456	019	0	1	01	01	H4456_019_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H4456	021	0	1	01	01	H4456_021_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	021	0	1	01	01	H4456_021_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H4456	021	0	1	01	01	H4456_021_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4456	021	0	1	01	01	H4456_021_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H4456	025	0	1	01	01	H4456_025_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4456	025	0	1	01	01	H4456_025_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4456	025	0	1	01	01	H4456_025_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4456	025	0	1	01	01	H4456_025_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	026	0	1	02	01	H4456_026_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4456	026	0	1	02	01	H4456_026_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4456	026	0	1	02	01	H4456_026_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4456	026	0	1	02	01	H4456_026_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4456	027	0	1	02	01	H4456_027_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						0.00			15.00		5.00			
H4456	027	0	1	02	01	H4456_027_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						110.00			120.00		40.00			
H4456	027	0	1	02	01	H4456_027_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4456	027	0	1	02	01	H4456_027_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4461	001	0	1	01	01	H4461_001_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4461	001	0	1	01	01	H4461_001_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4461	001	0	1	01	01	H4461_001_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4461	001	0	1	01	01	H4461_001_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H4461	001	0	1	01	01	H4461_001_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4461	001	0	1	01	01	H4461_001_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4461	001	0	1	01	01	H4461_001_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4461	001	0	1	01	01	H4461_001_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H4461	012	0	1	01	01	H4461_012_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4461	012	0	1	01	01	H4461_012_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H4461	012	0	1	01	01	H4461_012_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4461	012	0	1	01	01	H4461_012_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H4461	012	0	1	01	01	H4461_012_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4461	012	0	1	01	01	H4461_012_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H4461	012	0	1	01	01	H4461_012_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4461	012	0	1	01	01	H4461_012_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H4461	015	0	1	01	01	H4461_015_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4461	015	0	1	01	01	H4461_015_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4461	015	0	1	01	01	H4461_015_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4461	015	0	1	01	01	H4461_015_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H4461	015	0	1	01	01	H4461_015_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4461	015	0	1	01	01	H4461_015_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4461	015	0	1	01	01	H4461_015_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H4461	015	0	1	01	01	H4461_015_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4461	016	0	1	01	01	H4461_016_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4461	016	0	1	01	01	H4461_016_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4461	016	0	1	01	01	H4461_016_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H4461	016	0	1	01	01	H4461_016_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4461	016	0	1	01	01	H4461_016_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4461	016	0	1	01	01	H4461_016_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4461	016	0	1	01	01	H4461_016_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H4461	016	0	1	01	01	H4461_016_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4506	003	0	1	01	01	H4506_003_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
H4506	003	0	1	01	01	H4506_003_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H4506	003	0	1	01	01	H4506_003_0	7	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4506	003	0	1	01	01	H4506_003_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4506	003	0	1	01	01	H4506_003_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00	1	2	10000000
H4506	003	0	1	01	01	H4506_003_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00	1	1	
H4506	003	0	1	01	01	H4506_003_0	7	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H4506	003	0	1	01	01	H4506_003_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H4506	025	0	1	01	01	H4506_025_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H4506	025	0	1	01	01	H4506_025_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4506	025	0	1	01	01	H4506_025_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00	1	2	10000000
H4506	025	0	1	01	01	H4506_025_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00	1	1	
H4506	025	0	1	01	01	H4506_025_0	6	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H4506	025	0	1	01	01	H4506_025_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H4506	025	0	1	01	01	H4506_025_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H4506	025	0	1	01	01	H4506_025_0	6	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4510	012	0	1	01	01	H4510_012_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00			
H4510	012	0	1	01	01	H4510_012_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4510	012	0	1	01	01	H4510_012_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00	1	2	10000000
H4510	012	0	1	01	01	H4510_012_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00	1	2	10001000
H4510	012	0	1	01	01	H4510_012_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	00001000
H4510	012	0	1	01	01	H4510_012_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	012	0	1	01	01	H4510_012_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H4510	015	0	1	01	01	H4510_015_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00	1	2	10000000
H4510	015	0	1	01	01	H4510_015_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00	1	2	10001000
H4510	015	0	1	01	01	H4510_015_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00	1	2	00001000
H4510	015	0	1	01	01	H4510_015_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	015	0	1	01	01	H4510_015_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H4510	015	0	1	01	01	H4510_015_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	20.00	60.00								20.00					20.00	50.00		20.00	60.00		20.00			
H4510	015	0	1	01	01	H4510_015_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4510	017	0	1	01	01	H4510_017_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H4510	017	0	1	01	01	H4510_017_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	017	0	1	01	01	H4510_017_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4510	018	0	1	01	01	H4510_018_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4510	018	0	1	01	01	H4510_018_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4510	018	0	1	01	01	H4510_018_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4510	018	0	1	01	01	H4510_018_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4510	018	0	1	01	01	H4510_018_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4510	018	0	1	01	01	H4510_018_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	019	0	1	01	01	H4510_019_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00					60.00	150.00		60.00	180.00		60.00			
H4510	019	0	1	01	01	H4510_019_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	020	0	1	01	01	H4510_020_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4510	020	0	1	01	01	H4510_020_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4510	020	0	1	01	01	H4510_020_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4510	020	0	1	01	01	H4510_020_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00	1	2	10000000
H4510	020	0	1	01	01	H4510_020_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00					70.00	175.00		70.00	210.00		70.00			
H4510	020	0	1	01	01	H4510_020_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	020	0	1	01	01	H4510_020_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4510	020	0	1	01	01	H4510_020_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H4510	021	0	1	01	01	H4510_021_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H4510	021	0	1	01	01	H4510_021_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H4510	021	0	1	01	01	H4510_021_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00					95.00	237.50		95.00	285.00		95.00			
H4510	021	0	1	01	01	H4510_021_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	022	0	1	01	01	H4510_022_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00	1	2	10001000
H4510	022	0	1	01	01	H4510_022_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00	1	2	10000000
H4510	022	0	1	01	01	H4510_022_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4510	022	0	1	01	01	H4510_022_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4510	022	0	1	01	01	H4510_022_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	022	0	1	01	01	H4510_022_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00					55.00	137.50		55.00	165.00		55.00			
H4510	022	0	1	01	01	H4510_022_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00			
H4510	022	0	1	01	01	H4510_022_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H4510	023	0	1	01	01	H4510_023_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	12.00	36.00								12.00					12.00	30.00		12.00	36.00		12.00			
H4510	023	0	1	01	01	H4510_023_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	25.00	75.00								25.00					25.00	62.50		25.00	75.00		25.00			
H4510	023	0	1	01	01	H4510_023_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	023	0	1	01	01	H4510_023_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H4510	024	0	1	01	01	H4510_024_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4510	024	0	1	01	01	H4510_024_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	27.00	81.00								27.00					27.00	67.50		27.00	81.00		27.00			
H4510	024	0	1	01	01	H4510_024_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H4510	024	0	1	01	01	H4510_024_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00					56.00	140.00		56.00	168.00		56.00			
H4513	001	0	1	01	01	H4513_001_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H4513	001	0	1	01	01	H4513_001_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H4513	001	0	1	01	01	H4513_001_0	5	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H4513	001	0	1	01	01	H4513_001_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4513	001	0	1	01	01	H4513_001_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H4513	001	0	1	01	01	H4513_001_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4513	001	0	1	01	01	H4513_001_0	5	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4513	001	0	1	01	01	H4513_001_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4513	001	0	1	01	01	H4513_001_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4513	014	0	1	01	01	H4513_014_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	1	
H4513	014	0	1	01	01	H4513_014_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H4513	014	0	1	01	01	H4513_014_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H4513	014	0	1	01	01	H4513_014_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00			
H4513	014	0	1	01	01	H4513_014_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4513	014	0	1	01	01	H4513_014_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4513	014	0	1	01	01	H4513_014_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4513	014	0	1	01	01	H4513_014_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00	1	1	
H4513	014	0	1	01	01	H4513_014_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4513	014	0	1	01	01	H4513_014_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																								
H4513	019	0	1	01	01	H4513_019_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	2	01000000
H4513	019	0	1	01	01	H4513_019_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4513	019	0	1	01	01	H4513_019_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4513	019	0	1	01	01	H4513_019_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																								
H4513	019	0	1	01	01	H4513_019_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4513	019	0	1	01	01	H4513_019_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4513	019	0	1	01	01	H4513_019_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H4513	019	0	1	01	01	H4513_019_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4513	019	0	1	01	01	H4513_019_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4513	019	0	1	01	01	H4513_019_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H4513	020	0	1	01	01	H4513_020_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H4513	020	0	1	01	01	H4513_020_0	3	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4513	020	0	1	01	01	H4513_020_0	3	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4513	020	0	1	01	01	H4513_020_0	3	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4513	020	0	1	01	01	H4513_020_0	3	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4513	020	0	1	01	01	H4513_020_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4513	020	0	1	01	01	H4513_020_0	3	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4513	020	0	1	01	01	H4513_020_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4513	020	0	1	01	01	H4513_020_0	3	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H4513	020	0	1	01	01	H4513_020_0	3	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H4513	022	0	1	01	01	H4513_022_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4513	022	0	1	01	01	H4513_022_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4513	022	0	1	01	01	H4513_022_0	6	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4513	022	0	1	01	01	H4513_022_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4513	022	0	1	01	01	H4513_022_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4513	022	0	1	01	01	H4513_022_0	6	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4513	022	0	1	01	01	H4513_022_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H4513	022	0	1	01	01	H4513_022_0	6	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H4513	022	0	1	01	01	H4513_022_0	6	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4513	022	0	1	01	01	H4513_022_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H4514	004	0	1	01	01	H4514_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4514	004	0	1	01	01	H4514_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H4514	004	0	1	01	01	H4514_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H4514	004	0	1	01	01	H4514_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4514	007	0	1	01	01	H4514_007_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4514	007	0	1	01	01	H4514_007_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H4514	007	0	1	01	01	H4514_007_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H4514	007	0	1	01	01	H4514_007_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4520	001	0	1	04	01	H4520_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	001	0	1	04	01	H4520_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	001	0	1	04	01	H4520_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00	1	2	10001000
H4520	001	0	1	04	01	H4520_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	001	0	1	04	01	H4520_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	001	0	1	04	01	H4520_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	001	0	1	04	01	H4520_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00			
H4520	001	0	1	04	01	H4520_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	002	0	1	04	01	H4520_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	002	0	1	04	01	H4520_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	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	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4520	002	0	1	04	01	H4520_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H4520	002	0	1	04	01	H4520_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	002	0	1	04	01	H4520_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00					65.00	162.50		65.00	195.00		65.00	1	2	10000000
H4520	002	0	1	04	01	H4520_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H4520	003	0	1	04	01	H4520_003_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	003	0	1	04	01	H4520_003_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	003	0	1	04	01	H4520_003_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	003	0	1	04	01	H4520_003_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00			
H4520	003	0	1	04	01	H4520_003_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00	1	2	10001000
H4520	003	0	1	04	01	H4520_003_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	003	0	1	04	01	H4520_003_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	005	0	1	04	01	H4520_005_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	005	0	1	04	01	H4520_005_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	43.00	129.00								43.00					43.00	107.50		43.00	129.00		43.00			
H4520	005	0	1	04	01	H4520_005_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	005	0	1	04	01	H4520_005_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	005	0	1	04	01	H4520_005_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	005	0	1	04	01	H4520_005_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	43.00	129.00								43.00					43.00	107.50		43.00	129.00		43.00	1	2	10001000
H4520	005	0	1	04	01	H4520_005_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	005	0	1	04	01	H4520_005_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	006	0	1	04	01	H4520_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	006	0	1	04	01	H4520_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	43.00	129.00								43.00					43.00	107.50		43.00	129.00		43.00			
H4520	006	0	1	04	01	H4520_006_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	006	0	1	04	01	H4520_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	006	0	1	04	01	H4520_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	006	0	1	04	01	H4520_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	43.00	129.00								43.00					43.00	107.50		43.00	129.00		43.00	1	2	10001000
H4520	006	0	1	04	01	H4520_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	006	0	1	04	01	H4520_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	016	0	1	04	01	H4520_016_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	016	0	1	04	01	H4520_016_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00	1	2	10001000
H4520	016	0	1	04	01	H4520_016_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	016	0	1	04	01	H4520_016_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	016	0	1	04	01	H4520_016_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	016	0	1	04	01	H4520_016_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	016	0	1	04	01	H4520_016_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	41.00	123.00								41.00					41.00	102.50		41.00	123.00		41.00			
H4520	016	0	1	04	01	H4520_016_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	018	0	1	04	01	H4520_018_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	018	0	1	04	01	H4520_018_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00	1	2	10001000
H4520	018	0	1	04	01	H4520_018_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	018	0	1	04	01	H4520_018_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	018	0	1	04	01	H4520_018_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	018	0	1	04	01	H4520_018_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00			
H4520	018	0	1	04	01	H4520_018_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	018	0	1	04	01	H4520_018_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	020	0	1	04	01	H4520_020_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	020	0	1	04	01	H4520_020_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4520	020	0	1	04	01	H4520_020_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	020	0	1	04	01	H4520_020_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H4520	020	0	1	04	01	H4520_020_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	020	0	1	04	01	H4520_020_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	020	0	1	04	01	H4520_020_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H4520	020	0	1	04	01	H4520_020_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	021	0	1	04	01	H4520_021_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4520	021	0	1	04	01	H4520_021_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4520	021	0	1	04	01	H4520_021_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4520	021	0	1	04	01	H4520_021_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00			
H4520	021	0	1	04	01	H4520_021_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4520	021	0	1	04	01	H4520_021_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H4520	021	0	1	04	01	H4520_021_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00	1	2	10001000
H4520	021	0	1	04	01	H4520_021_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4522	001	0	1	04	01	H4522_001_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4522	001	0	1	04	01	H4522_001_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H4522	001	0	1	04	01	H4522_001_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H4522	001	0	1	04	01	H4522_001_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4522	001	0	1	04	01	H4522_001_0	6	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00	1	1	
H4522	001	0	1	04	01	H4522_001_0	6	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H4522	001	0	1	04	01	H4522_001_0	6	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H4522	001	0	1	04	01	H4522_001_0	6	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H4522	008	0	1	04	01	H4522_008_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4522	008	0	1	04	01	H4522_008_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H4522	008	0	1	04	01	H4522_008_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H4522	008	0	1	04	01	H4522_008_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4523	001	0	1	01	01	H4523_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	001	0	1	01	01	H4523_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H4523	001	0	1	01	01	H4523_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H4523	001	0	1	01	01	H4523_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H4523	001	0	1	01	01	H4523_001_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4523	001	0	1	01	01	H4523_001_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H4523	001	0	1	01	01	H4523_001_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4523	001	0	1	01	01	H4523_001_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																						2		
H4523	001	0	1	01	01	H4523_001_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4523	001	0	1	01	01	H4523_001_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H4523	005	0	1	01	01	H4523_005_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H4523	005	0	1	01	01	H4523_005_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H4523	005	0	1	01	01	H4523_005_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				33.00	82.50		33.00	99.00			33.00					66.00			99.00		33.00			
H4523	005	0	1	01	01	H4523_005_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00			
H4523	005	0	1	01	01	H4523_005_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H4523	014	0	1	01	01	H4523_014_0	6	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				20.00	50.00		20.00	60.00			20.00					40.00			60.00		20.00			
H4523	014	0	1	01	01	H4523_014_0	6	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H4523	014	0	1	01	01	H4523_014_0	6	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H4523	014	0	1	01	01	H4523_014_0	6	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	014	0	1	01	01	H4523_014_0	6	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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	015	0	1	01	01	H4523_015_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H4523	015	0	1	01	01	H4523_015_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4523	015	0	1	01	01	H4523_015_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																						2		
H4523	015	0	1	01	01	H4523_015_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4523	015	0	1	01	01	H4523_015_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H4523	015	0	1	01	01	H4523_015_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				78.00	195.00		78.00	234.00			78.00					156.00			234.00		78.00			
H4523	015	0	1	01	01	H4523_015_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4523	015	0	1	01	01	H4523_015_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		28.00	84.00			28.00					56.00			84.00		28.00			
H4523	015	0	1	01	01	H4523_015_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H4523	015	0	1	01	01	H4523_015_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				37.00	92.50		37.00	111.00			37.00					74.00			111.00		37.00			
H4524	001	0	1	04	01	H4524_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					64.00			96.00		32.00			
H4524	001	0	1	04	01	H4524_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H4524	001	0	1	04	01	H4524_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	001	0	1	04	01	H4524_001_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H4524	001	0	1	04	01	H4524_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				9.00	22.50		9.00	27.00			9.00					18.00			27.00		9.00			
H4524	002	0	1	04	01	H4524_002_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4524	002	0	1	04	01	H4524_002_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																						2		
H4524	002	0	1	04	01	H4524_002_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4524	002	0	1	04	01	H4524_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																						2		
H4524	002	0	1	04	01	H4524_002_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H4524	002	0	1	04	01	H4524_002_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H4524	002	0	1	04	01	H4524_002_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	002	0	1	04	01	H4524_002_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H4524	002	0	1	04	01	H4524_002_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H4524	002	0	1	04	01	H4524_002_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H4524	007	0	1	04	01	H4524_007_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	007	0	1	04	01	H4524_007_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H4524	007	0	1	04	01	H4524_007_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				82.00	205.00		82.00	246.00			82.00					164.00			246.00		82.00			
H4524	007	0	1	04	01	H4524_007_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H4524	007	0	1	04	01	H4524_007_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				36.00	90.00		36.00	108.00			36.00					72.00			108.00		36.00			
H4524	008	0	1	04	01	H4524_008_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4524	008	0	1	04	01	H4524_008_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4524	008	0	1	04	01	H4524_008_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																						2		
H4524	008	0	1	04	01	H4524_008_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4524	008	0	1	04	01	H4524_008_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					76.00			114.00		38.00			
H4524	008	0	1	04	01	H4524_008_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H4524	008	0	1	04	01	H4524_008_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				78.00	195.00		78.00	234.00			78.00					156.00			234.00		78.00			
H4524	008	0	1	04	01	H4524_008_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H4524	008	0	1	04	01	H4524_008_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H4524	008	0	1	04	01	H4524_008_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H4524	013	0	1	04	01	H4524_013_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H4524	013	0	1	04	01	H4524_013_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					76.00			114.00		38.00			
H4524	013	0	1	04	01	H4524_013_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					64.00			96.00		32.00			
H4524	013	0	1	04	01	H4524_013_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H4524	014	0	1	04	01	H4524_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																						2		
H4524	014	0	1	04	01	H4524_014_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4524	014	0	1	04	01	H4524_014_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H4524	014	0	1	04	01	H4524_014_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H4524	014	0	1	04	01	H4524_014_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4524	014	0	1	04	01	H4524_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																						2		
H4524	014	0	1	04	01	H4524_014_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	014	0	1	04	01	H4524_014_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H4524	014	0	1	04	01	H4524_014_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H4524	014	0	1	04	01	H4524_014_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H4525	001	0	1	01	01	H4525_001_0	6	3	2	1	Specialty	100000		1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	25	25									25	25	25								25	Specialty																								
H4525	001	0	1	01	01	H4525_001_0	6	2	2	1	Brand	000010		2	1	Brand	111000000001110000000	31	90									10	31	90								31	2	Brand	2	Brand																						Brand	27.00	81.00									27.00	27.00	81.00								27.00			
H4525	001	0	1	01	01	H4525_001_0	6	1	2	1	Generics	010000		2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	7.00	21.00									7.00	7.00	21.00								7.00			
H4525	002	0	1	01	01	H4525_002_0	5	1	2	1	Generics	010000		2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	7.00	21.00									7.00	7.00	21.00								7.00			
H4525	002	0	1	01	01	H4525_002_0	5	2	2	1	Brand	000010		2	1	Brand	111000000001110000000	31	90									10	31	90								31	2	Brand	2	Brand																						Brand	28.00	84.00									28.00	28.00	84.00								28.00			
H4525	002	0	1	01	01	H4525_002_0	5	3	2	1	Specialty	100000		1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	25	25									25	25	25								25	Specialty																								
H4525	007	0	1	01	01	H4525_007_0	3	3	4	3	Specialty	100000	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4525	007	0	1	01	01	H4525_007_0	3	2	4	3	Brands	000010	1	2	1	Brands																								Brands		Brands																						Brands																						2		
H4525	007	0	1	01	01	H4525_007_0	3	1	4	3	Generics	010000	1	2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	12.50								5.00	1	1	
H4525	007	0	1	01	01	H4525_007_0	3	3	4	1	Specialty	100000	1	1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H4525	007	0	1	01	01	H4525_007_0	3	1	4	1	Generics	010000	1	2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	12.50								5.00			
H4525	007	0	1	01	01	H4525_007_0	3	2	4	1	Brands	000010	1	2	1	Brands	111000000001110000000	31	90									10	31	90								31	2	Brands	2	Brands																						Brands	30.00	90.00									30.00	30.00	75.00								30.00			
H4525	008	0	1	01	01	H4525_008_0	3	1	4	1	Generics	010000	1	2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	12.50								5.00			
H4525	008	0	1	01	01	H4525_008_0	3	2	4	1	Brands	000010	1	2	1	Brands	111000000001110000000	31	90									10	31	90								31	2	Brands	2	Brands																						Brands	30.00	90.00									30.00	30.00	75.00								30.00			
H4525	008	0	1	01	01	H4525_008_0	3	2	4	3	Brands	000010	1	2	1	Brands																								Brands		Brands																						Brands																						2		
H4525	008	0	1	01	01	H4525_008_0	3	1	4	3	Generics	010000	1	2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	12.50								5.00	1	1	
H4525	008	0	1	01	01	H4525_008_0	3	3	4	3	Specialty	100000	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4525	008	0	1	01	01	H4525_008_0	3	3	4	1	Specialty	100000	1	1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H4525	009	0	1	01	01	H4525_009_0	3	3	4	3	Specialty	100000	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4525	009	0	1	01	01	H4525_009_0	3	2	4	3	Brands	000010	1	2	1	Brands																								Brands		Brands																						Brands																						2		
H4525	009	0	1	01	01	H4525_009_0	3	1	4	3	Generics	010000	1	2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	12.50								5.00	1	1	
H4525	009	0	1	01	01	H4525_009_0	3	2	4	1	Brands	000010	1	2	1	Brands	111000000001110000000	31	90									10	31	90								31	2	Brands	2	Brands																						Brands	30.00	90.00									30.00	30.00	75.00								30.00			
H4525	009	0	1	01	01	H4525_009_0	3	1	4	1	Generics	010000	1	2	2	Generics	111000000001110000000	31	90									10	31	90								31	2	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	12.50								5.00			
H4525	009	0	1	01	01	H4525_009_0	3	3	4	1	Specialty	100000	1	1	2	Specialty	111000000001110000000	31	90									10	31	90								31	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H4527	001	0	1	01	01	H4527_001_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00			
H4527	001	0	1	01	01	H4527_001_0	5	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	001	0	1	01	01	H4527_001_0	5	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	001	0	1	01	01	H4527_001_0	5	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H4527	001	0	1	01	01	H4527_001_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00	1	1	
H4527	001	0	1	01	01	H4527_001_0	5	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	001	0	1	01	01	H4527_001_0	5	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	001	0	1	01	01	H4527_001_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H4527	002	0	1	01	01	H4527_002_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H4527	002	0	1	01	01	H4527_002_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H4527	002	0	1	01	01	H4527_002_0	7	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	002	0	1	01	01	H4527_002_0	7	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	002	0	1	01	01	H4527_002_0	7	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00	1	1	
H4527	002	0	1	01	01	H4527_002_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	002	0	1	01	01	H4527_002_0	7	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	002	0	1	01	01	H4527_002_0	7	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	005	0	1	01	01	H4527_005_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H4527	005	0	1	01	01	H4527_005_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H4527	005	0	1	01	01	H4527_005_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	005	0	1	01	01	H4527_005_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	005	0	1	01	01	H4527_005_0	4	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H4527	005	0	1	01	01	H4527_005_0	4	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	005	0	1	01	01	H4527_005_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	005	0	1	01	01	H4527_005_0	4	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	008	0	1	01	01	H4527_008_0	4	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	008	0	1	01	01	H4527_008_0	4	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H4527	008	0	1	01	01	H4527_008_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			60.00								25.00			
H4527	008	0	1	01	01	H4527_008_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	008	0	1	01	01	H4527_008_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	008	0	1	01	01	H4527_008_0	4	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H4527	008	0	1	01	01	H4527_008_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	008	0	1	01	01	H4527_008_0	4	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	013	0	1	01	01	H4527_013_0	5	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	013	0	1	01	01	H4527_013_0	5	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	013	0	1	01	01	H4527_013_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	013	0	1	01	01	H4527_013_0	5	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00	1	1	
H4527	013	0	1	01	01	H4527_013_0	5	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	013	0	1	01	01	H4527_013_0	5	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	013	0	1	01	01	H4527_013_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H4527	013	0	1	01	01	H4527_013_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H4527	014	0	1	01	01	H4527_014_0	5	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	014	0	1	01	01	H4527_014_0	5	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	014	0	1	01	01	H4527_014_0	5	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00	1	1	
H4527	014	0	1	01	01	H4527_014_0	5	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	014	0	1	01	01	H4527_014_0	5	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	014	0	1	01	01	H4527_014_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H4527	014	0	1	01	01	H4527_014_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H4527	014	0	1	01	01	H4527_014_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	023	0	1	01	01	H4527_023_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H4527	023	0	1	01	01	H4527_023_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	023	0	1	01	01	H4527_023_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	023	0	1	01	01	H4527_023_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H4527	026	0	1	01	01	H4527_026_0	4	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H4527	026	0	1	01	01	H4527_026_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	026	0	1	01	01	H4527_026_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	026	0	1	01	01	H4527_026_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			60.00								25.00			
H4527	026	0	1	01	01	H4527_026_0	4	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H4527	026	0	1	01	01	H4527_026_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	026	0	1	01	01	H4527_026_0	4	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	026	0	1	01	01	H4527_026_0	4	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	027	0	1	01	01	H4527_027_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H4527	027	0	1	01	01	H4527_027_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			60.00								25.00			
H4527	027	0	1	01	01	H4527_027_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	027	0	1	01	01	H4527_027_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	028	0	1	01	01	H4527_028_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			0.00								3.00			
H4527	028	0	1	01	01	H4527_028_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	028	0	1	01	01	H4527_028_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			60.00								25.00			
H4527	028	0	1	01	01	H4527_028_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4527	030	0	1	01	01	H4527_030_0	5	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H4527	030	0	1	01	01	H4527_030_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H4527	030	0	1	01	01	H4527_030_0	5	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H4527	030	0	1	01	01	H4527_030_0	5	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H4527	030	0	1	01	01	H4527_030_0	5	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H4527	030	0	1	01	01	H4527_030_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00			60.00								25.00			
H4527	030	0	1	01	01	H4527_030_0	5	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H4527	030	0	1	01	01	H4527_030_0	5	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H4528	001	0	1	02	01	H4528_001_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00			
H4528	001	0	1	02	01	H4528_001_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H4528	001	0	1	02	01	H4528_001_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00			
H4528	005	0	1	02	01	H4528_005_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H4528	014	0	1	01	01	H4528_014_0	2	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H4528	014	0	1	01	01	H4528_014_0	2	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4528	014	0	1	01	01	H4528_014_0	2	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4528	014	0	1	01	01	H4528_014_0	2	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H4528	014	0	1	01	01	H4528_014_0	2	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H4528	014	0	1	01	01	H4528_014_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H4528	014	0	1	01	01	H4528_014_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H4528	014	0	1	01	01	H4528_014_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H4528	014	0	1	01	01	H4528_014_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00			
H4528	014	0	1	01	01	H4528_014_0	2	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H4528	015	0	1	01	01	H4528_015_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00		3.00	6.00								3.00			
H4528	015	0	1	01	01	H4528_015_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H4528	015	0	1	01	01	H4528_015_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H4528	015	0	1	01	01	H4528_015_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H4528	015	0	1	01	01	H4528_015_0	2	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H4528	015	0	1	01	01	H4528_015_0	2	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H4528	015	0	1	01	01	H4528_015_0	2	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4528	015	0	1	01	01	H4528_015_0	2	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4528	015	0	1	01	01	H4528_015_0	2	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H4528	015	0	1	01	01	H4528_015_0	2	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H4529	002	0	1	02	01	H4529_002_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																						2		
H4529	002	0	1	02	01	H4529_002_0	10	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4529	002	0	1	02	01	H4529_002_0	10	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H4529	002	0	1	02	01	H4529_002_0	10	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H4529	002	0	1	02	01	H4529_002_0	10	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H4529	002	0	1	02	01	H4529_002_0	10	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H4529	002	0	1	02	01	H4529_002_0	10	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00			
H4529	002	0	1	02	01	H4529_002_0	10	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4529	002	0	1	02	01	H4529_002_0	10	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4529	002	0	1	02	01	H4529_002_0	10	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H4529	004	0	1	01	01	H4529_004_0	10	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4529	004	0	1	01	01	H4529_004_0	10	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H4529	004	0	1	01	01	H4529_004_0	10	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4529	004	0	1	01	01	H4529_004_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																						2		
H4529	004	0	1	01	01	H4529_004_0	10	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4529	004	0	1	01	01	H4529_004_0	10	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H4529	004	0	1	01	01	H4529_004_0	10	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	25	25								25			25								25	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4529	004	0	1	01	01	H4529_004_0	10	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4529	004	0	1	01	01	H4529_004_0	10	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H4529	004	0	1	01	01	H4529_004_0	10	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H4529	014	0	1	01	01	H4529_014_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H4529	014	0	1	01	01	H4529_014_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4529	014	0	1	01	01	H4529_014_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																						2		
H4529	014	0	1	01	01	H4529_014_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H4529	014	0	1	01	01	H4529_014_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4529	014	0	1	01	01	H4529_014_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H4529	014	0	1	01	01	H4529_014_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H4529	014	0	1	01	01	H4529_014_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4529	014	0	1	01	01	H4529_014_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4529	014	0	1	01	01	H4529_014_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H4529	027	0	1	01	01	H4529_027_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H4529	027	0	1	01	01	H4529_027_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H4529	027	0	1	01	01	H4529_027_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H4529	027	0	1	01	01	H4529_027_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																						2		
H4529	027	0	1	01	01	H4529_027_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4529	027	0	1	01	01	H4529_027_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H4529	027	0	1	01	01	H4529_027_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4529	027	0	1	01	01	H4529_027_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H4529	027	0	1	01	01	H4529_027_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H4529	027	0	1	01	01	H4529_027_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H4529	028	0	1	01	01	H4529_028_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4529	028	0	1	01	01	H4529_028_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4529	028	0	1	01	01	H4529_028_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H4529	028	0	1	01	01	H4529_028_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																						2		
H4529	028	0	1	01	01	H4529_028_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4529	028	0	1	01	01	H4529_028_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H4529	028	0	1	01	01	H4529_028_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4529	028	0	1	01	01	H4529_028_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H4529	028	0	1	01	01	H4529_028_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H4529	028	0	1	01	01	H4529_028_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H4529	030	0	1	01	01	H4529_030_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H4529	030	0	1	01	01	H4529_030_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H4529	030	0	1	01	01	H4529_030_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H4529	030	0	1	01	01	H4529_030_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H4529	030	0	1	01	01	H4529_030_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H4529	030	0	1	01	01	H4529_030_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																						2		
H4529	030	0	1	01	01	H4529_030_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4529	030	0	1	01	01	H4529_030_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4529	030	0	1	01	01	H4529_030_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H4529	030	0	1	01	01	H4529_030_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4564	001	0	1	18	06	H4564_001_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	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	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	9	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	9	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
H4564	002	0	1	18	06	H4564_002_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	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	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	7	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	7	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
H4564	003	0	1	18	06	H4564_003_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	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	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	7	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	7	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
H4564	004	0	1	18	06	H4564_004_0	9	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00		0.00	0.00								0.00			
H4564	004	0	1	18	06	H4564_004_0	9	4	4	3	Specialty	111111	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4564	004	0	1	18	06	H4564_004_0	9	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
H4564	004	0	1	18	06	H4564_004_0	9	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00	1	1	
H4564	004	0	1	18	06	H4564_004_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4564	004	0	1	18	06	H4564_004_0	9	3	4	3	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic																								Non-Preferred Brand or Generic		Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																						2		
H4564	005	0	1	18	06	H4564_005_0	7	4	4	3	Specialty	111111	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4564	005	0	1	18	06	H4564_005_0	7	3	4	3	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic																								Non-Preferred Brand or Generic		Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																						2		
H4564	005	0	1	18	06	H4564_005_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4564	005	0	1	18	06	H4564_005_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00	1	1	
H4564	005	0	1	18	06	H4564_005_0	7	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
H4564	005	0	1	18	06	H4564_005_0	7	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	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	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	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	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	7	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	7	4	4	3	Specialty	111111	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4564	006	0	1	18	06	H4564_006_0	7	3	4	3	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic																								Non-Preferred Brand or Generic		Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																						2		
H4564	006	0	1	18	06	H4564_006_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4564	006	0	1	18	06	H4564_006_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00	1	1	
H4564	006	0	1	18	06	H4564_006_0	7	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
H4564	013	0	1	18	06	H4564_013_0	9	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00		5.00	10.00								5.00			
H4564	013	0	1	18	06	H4564_013_0	9	4	3	1	Specialty	111111		1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	25	25	25							25		25	25								25	Specialty																								
H4564	013	0	1	18	06	H4564_013_0	9	3	3	1	Non-Preferred Brand or Generic	100100		2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	9	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00								30.00			
H4564	014	0	1	18	06	H4564_014_0	7	4	3	1	Specialty	111111		1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	25	25	25							25		25	25								25	Specialty																								
H4564	014	0	1	18	06	H4564_014_0	7	3	3	1	Non-Preferred Brand or Generic	100100		2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	7	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00								30.00			
H4564	014	0	1	18	06	H4564_014_0	7	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00		5.00	10.00								5.00			
H4564	015	0	1	18	06	H4564_015_0	8	3	3	1	Non-Preferred Brand or Generic	100100		2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00								30.00			
H4564	015	0	1	18	06	H4564_015_0	8	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00	10.00							5.00		5.00	10.00								5.00			
H4564	015	0	1	18	06	H4564_015_0	8	4	3	1	Specialty	111111		1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	25	25	25							25		25	25								25	Specialty																								
H4590	010	0	1	01	01	H4590_010_0	4	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H4590	010	0	1	01	01	H4590_010_0	4	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H4590	010	0	1	01	01	H4590_010_0	4	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H4590	010	0	1	01	01	H4590_010_0	4	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						0.00			15.00		5.00	1	1	
H4590	010	0	1	01	01	H4590_010_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4590	010	0	1	01	01	H4590_010_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	60.00	180.00								60.00						170.00			180.00		60.00			
H4590	010	0	1	01	01	H4590_010_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	29.00	87.00								29.00						0.00			87.00		29.00			
H4590	010	0	1	01	01	H4590_010_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						0.00			15.00		5.00			
H4590	012	0	1	01	01	H4590_012_0	7	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H4590	012	0	1	01	01	H4590_012_0	7	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H4590	012	0	1	01	01	H4590_012_0	7	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H4590	012	0	1	01	01	H4590_012_0	7	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00	1	1	
H4590	012	0	1	01	01	H4590_012_0	7	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4590	012	0	1	01	01	H4590_012_0	7	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H4590	012	0	1	01	01	H4590_012_0	7	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H4590	012	0	1	01	01	H4590_012_0	7	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4590	025	0	1	01	01	H4590_025_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4590	025	0	1	01	01	H4590_025_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H4590	025	0	1	01	01	H4590_025_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H4590	025	0	1	01	01	H4590_025_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4590	035	0	1	01	01	H4590_035_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4590	035	0	1	01	01	H4590_035_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H4590	035	0	1	01	01	H4590_035_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H4590	035	0	1	01	01	H4590_035_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4590	036	0	1	01	01	H4590_036_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H4590	036	0	1	01	01	H4590_036_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4590	036	0	1	01	01	H4590_036_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H4590	036	0	1	01	01	H4590_036_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4590	037	0	1	01	01	H4590_037_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	71.00	213.00								71.00						203.00			213.00		71.00			
H4590	037	0	1	01	01	H4590_037_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H4590	037	0	1	01	01	H4590_037_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4590	037	0	1	01	01	H4590_037_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00	1	1	
H4590	037	0	1	01	01	H4590_037_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H4590	037	0	1	01	01	H4590_037_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H4590	037	0	1	01	01	H4590_037_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H4604	003	0	1	02	01	H4604_003_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4604	003	0	1	02	01	H4604_003_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H4604	003	0	1	02	01	H4604_003_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H4604	003	0	1	02	01	H4604_003_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4604	008	0	1	02	01	H4604_008_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4604	008	0	1	02	01	H4604_008_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H4604	008	0	1	02	01	H4604_008_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H4604	008	0	1	02	01	H4604_008_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4605	002	0	1	04	01	H4605_002_0	5	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	27									27		27									27	Miscellaneous Injectables																								
H4605	002	0	1	04	01	H4605_002_0	5	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	27									27		27									27	Specialty																								
H4605	002	0	1	04	01	H4605_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H4605	002	0	1	04	01	H4605_002_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H4605	002	0	1	04	01	H4605_002_0	5	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H4605	004	0	1	04	01	H4605_004_0	5	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
H4605	004	0	1	04	01	H4605_004_0	5	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
H4605	004	0	1	04	01	H4605_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H4605	004	0	1	04	01	H4605_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H4605	004	0	1	04	01	H4605_004_0	5	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H4605	004	0	1	04	01	H4605_004_0	5	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
H4605	004	0	1	04	01	H4605_004_0	5	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H4605	004	0	1	04	01	H4605_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H4605	004	0	1	04	01	H4605_004_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4605	004	0	1	04	01	H4605_004_0	5	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
H4606	001	0	1	04	01	H4606_001_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10000000
H4606	001	0	1	04	01	H4606_001_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4606	001	0	1	04	01	H4606_001_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4606	001	0	1	04	01	H4606_001_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4606	001	0	1	04	01	H4606_001_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4606	001	0	1	04	01	H4606_001_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4606	001	0	1	04	01	H4606_001_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H4606	001	0	1	04	01	H4606_001_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H4754	001	0	1	04	01	H4754_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	110.00								55.00			110.00								55.00			
H4754	001	0	1	04	01	H4754_001_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00			
H4754	001	0	1	04	01	H4754_001_0	5	1	4	1	Generic	001100	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H4754	001	0	1	04	01	H4754_001_0	5	4	4	1	Specialty	101101	1	1	2	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H4774	001	0	1	09	04	H4774_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4774	001	0	1	09	04	H4774_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4774	001	0	1	09	04	H4774_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4774	001	0	1	09	04	H4774_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H4774	001	0	1	09	04	H4774_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4774	001	0	1	09	04	H4774_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4774	001	0	1	09	04	H4774_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4774	001	0	1	09	04	H4774_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H4774	002	0	1	09	04	H4774_002_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4774	002	0	1	09	04	H4774_002_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00					90.00	225.00		90.00	270.00		90.00			
H4774	002	0	1	09	04	H4774_002_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4774	002	0	1	09	04	H4774_002_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
H4774	002	0	1	09	04	H4774_002_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4774	002	0	1	09	04	H4774_002_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00					90.00	225.00		90.00	270.00		90.00	1	2	10000000
H4774	002	0	1	09	04	H4774_002_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4774	002	0	1	09	04	H4774_002_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
H4774	003	0	1	09	04	H4774_003_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4774	003	0	1	09	04	H4774_003_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4774	003	0	1	09	04	H4774_003_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4774	003	0	1	09	04	H4774_003_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4774	003	0	1	09	04	H4774_003_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H4774	003	0	1	09	04	H4774_003_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4774	003	0	1	09	04	H4774_003_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4774	003	0	1	09	04	H4774_003_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H4774	004	0	1	09	04	H4774_004_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4774	004	0	1	09	04	H4774_004_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4774	004	0	1	09	04	H4774_004_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H4774	004	0	1	09	04	H4774_004_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H4774	004	0	1	09	04	H4774_004_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4774	004	0	1	09	04	H4774_004_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4774	004	0	1	09	04	H4774_004_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4774	004	0	1	09	04	H4774_004_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H4779	001	0	1	37	05	H4779_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4779	001	0	1	37	05	H4779_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H4779	001	0	1	37	05	H4779_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H4779	001	0	1	37	05	H4779_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4779	003	0	1	37	05	H4779_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H4779	003	0	1	37	05	H4779_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H4779	003	0	1	37	05	H4779_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H4779	003	0	1	37	05	H4779_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H4875	001	0	1	04	01	H4875_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H4875	001	0	1	04	01	H4875_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H4875	001	0	1	04	01	H4875_001_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H4875	001	0	1	04	01	H4875_001_0	7	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H4875	003	0	1	04	01	H4875_003_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H4875	003	0	1	04	01	H4875_003_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H4875	003	0	1	04	01	H4875_003_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H4875	003	0	1	04	01	H4875_003_0	7	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H4875	005	0	1	04	01	H4875_005_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H4875	005	0	1	04	01	H4875_005_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H4875	005	0	1	04	01	H4875_005_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H4875	005	0	1	04	01	H4875_005_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H4875	007	0	1	04	01	H4875_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H4875	007	0	1	04	01	H4875_007_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H4875	007	0	1	04	01	H4875_007_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H4875	007	0	1	04	01	H4875_007_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H4875	009	0	1	04	01	H4875_009_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
H4875	009	0	1	04	01	H4875_009_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H4875	009	0	1	04	01	H4875_009_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			150.00								60.00			
H4875	009	0	1	04	01	H4875_009_0	6	4	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	25									25		25									25	Specialty Tier																								
H4908	002	0	1	04	01	H4908_002_0	5	1	4	1	Generic	010000	1	2	2	Generic	111100000010010000000	31	90	60							31			90								34	1	Generic	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00			
H4908	002	0	1	04	01	H4908_002_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010010000000	31	90	60							31			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00			
H4908	002	0	1	04	01	H4908_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010010000000	31	90	60							31			90								34	1	Non-Preferred Brand	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	5	4	4	1	Specialty	010010	1	1	2	Specialty	111100000010010000000	31	90	60							31			90								34	1	Specialty	1	Specialty	30	30	30							30			30								30	Specialty																								
H4908	006	0	1	04	01	H4908_006_0	8	4	4	1	Specialty	010010	1	1	2	Specialty	111100000010010000000	31	90	60							31			90								34	1	Specialty	1	Specialty	30	30	30							30			30								30	Specialty																								
H4908	006	0	1	04	01	H4908_006_0	8	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010010000000	31	90	60							31			90								34	1	Non-Preferred Brand	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	8	1	4	1	Generic	010000	1	2	2	Generic	111100000010010000000	31	90	60							31			90								34	1	Generic	2	Generic																						Generic	4.00	12.00	8.00							4.00			12.00								4.00			
H4908	006	0	1	04	01	H4908_006_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010010000000	31	90	60							31			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00			90.00								30.00			
H4909	001	0	1	04	01	H4909_001_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H4909	001	0	1	04	01	H4909_001_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H4909	001	0	1	04	01	H4909_001_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H4909	001	0	1	04	01	H4909_001_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H4909	001	0	1	04	01	H4909_001_0	9	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H4909	001	0	1	04	01	H4909_001_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H4909	001	0	1	04	01	H4909_001_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H4909	001	0	1	04	01	H4909_001_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H4909	001	0	1	04	01	H4909_001_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H4909	001	0	1	04	01	H4909_001_0	9	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H4909	004	0	1	04	01	H4909_004_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H4909	004	0	1	04	01	H4909_004_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H4909	004	0	1	04	01	H4909_004_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H4909	004	0	1	04	01	H4909_004_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H4909	004	0	1	04	01	H4909_004_0	9	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H4909	004	0	1	04	01	H4909_004_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H4909	004	0	1	04	01	H4909_004_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H4909	004	0	1	04	01	H4909_004_0	9	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H4909	004	0	1	04	01	H4909_004_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H4909	004	0	1	04	01	H4909_004_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H4910	004	0	1	01	01	H4910_004_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H4910	004	0	1	01	01	H4910_004_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	31.00	93.00									31.00					62.00			93.00		31.00			
H4910	004	0	1	01	01	H4910_004_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	33.00	99.00									33.00					66.00			99.00		33.00			
H4910	004	0	1	01	01	H4910_004_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	76.00	228.00									76.00					152.00			228.00		76.00			
H4910	004	0	1	01	01	H4910_004_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H4910	005	0	1	01	01	H4910_005_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H4910	005	0	1	01	01	H4910_005_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																						2		
H4910	005	0	1	01	01	H4910_005_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H4910	005	0	1	01	01	H4910_005_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H4910	005	0	1	01	01	H4910_005_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H4910	005	0	1	01	01	H4910_005_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H4910	005	0	1	01	01	H4910_005_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H4910	005	0	1	01	01	H4910_005_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H4910	005	0	1	01	01	H4910_005_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H4910	005	0	1	01	01	H4910_005_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H4917	001	0	1	09	04	H4917_001_0	8	6	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4917	001	0	1	09	04	H4917_001_0	8	5	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H4917	001	0	1	09	04	H4917_001_0	8	2	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4917	001	0	1	09	04	H4917_001_0	8	3	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic																								Non-Preferred Generic		Non-Preferred Generic																						Non-Preferred Generic																						2		
H4917	001	0	1	09	04	H4917_001_0	8	4	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4917	001	0	1	09	04	H4917_001_0	8	5	4	3	Non-Preferred Brand	100000	1	2	1																																																																							2		
H4917	001	0	1	09	04	H4917_001_0	8	6	4	3	Specialty	010010	1	1	2																																																																							2		
H4917	001	0	1	09	04	H4917_001_0	8	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H4917	001	0	1	09	04	H4917_001_0	8	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H4917	001	0	1	09	04	H4917_001_0	8	2	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4917	001	0	1	09	04	H4917_001_0	8	3	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	12.00	36.00								12.00			36.00								12.00			
H4917	001	0	1	09	04	H4917_001_0	8	4	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H4917	002	0	1	09	04	H4917_002_0	7	4	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H4917	002	0	1	09	04	H4917_002_0	7	5	4	3	Non-Preferred Brand	100000	1	2	1																																																																							2		
H4917	002	0	1	09	04	H4917_002_0	7	6	4	3	Specialty	010010	1	1	2																																																																							2		
H4917	002	0	1	09	04	H4917_002_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H4917	002	0	1	09	04	H4917_002_0	7	2	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H4917	002	0	1	09	04	H4917_002_0	7	5	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H4917	002	0	1	09	04	H4917_002_0	7	4	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H4917	002	0	1	09	04	H4917_002_0	7	3	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic																								Non-Preferred Generic		Non-Preferred Generic																						Non-Preferred Generic																						2		
H4917	002	0	1	09	04	H4917_002_0	7	2	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H4917	002	0	1	09	04	H4917_002_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H4917	002	0	1	09	04	H4917_002_0	7	6	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H4917	002	0	1	09	04	H4917_002_0	7	3	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	12.00	36.00								12.00			36.00								12.00			
H4956	001	0	1	04	01	H4956_001_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4956	001	0	1	04	01	H4956_001_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4956	001	0	1	04	01	H4956_001_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H4956	001	0	1	04	01	H4956_001_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H4956	001	0	1	04	01	H4956_001_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4956	001	0	1	04	01	H4956_001_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4956	002	0	1	04	01	H4956_002_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4956	002	0	1	04	01	H4956_002_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H4956	002	0	1	04	01	H4956_002_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4956	002	0	1	04	01	H4956_002_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4956	002	0	1	04	01	H4956_002_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4956	002	0	1	04	01	H4956_002_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H4956	002	0	1	04	01	H4956_002_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4956	003	0	1	04	01	H4956_003_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H4956	003	0	1	04	01	H4956_003_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4956	003	0	1	04	01	H4956_003_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4956	003	0	1	04	01	H4956_003_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H4956	003	0	1	04	01	H4956_003_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H4956	003	0	1	04	01	H4956_003_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4956	003	0	1	04	01	H4956_003_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4956	003	0	1	04	01	H4956_003_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4956	004	0	1	04	01	H4956_004_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H4956	004	0	1	04	01	H4956_004_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H4956	004	0	1	04	01	H4956_004_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H4956	004	0	1	04	01	H4956_004_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H4956	004	0	1	04	01	H4956_004_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H4956	004	0	1	04	01	H4956_004_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generics / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generics / Preferred Brand	2	Non-Preferred Generics / Preferred Brand																						Non-Preferred Generics / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H4956	004	0	1	04	01	H4956_004_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H4956	004	0	1	04	01	H4956_004_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H4971	001	0	1	02	01	H4971_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H4971	001	0	1	02	01	H4971_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H4971	001	0	1	02	01	H4971_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H4971	001	0	1	02	01	H4971_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5005	001	0	1	01	01	H5005_001_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5005	001	0	1	01	01	H5005_001_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H5005	001	0	1	01	01	H5005_001_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H5005	001	0	1	01	01	H5005_001_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5005	010	0	1	01	01	H5005_010_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H5005	010	0	1	01	01	H5005_010_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H5005	010	0	1	01	01	H5005_010_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5005	011	0	1	01	01	H5005_011_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H5005	011	0	1	01	01	H5005_011_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5005	011	0	1	01	01	H5005_011_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H5005	011	0	1	01	01	H5005_011_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5005	019	0	1	01	01	H5005_019_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	39.00	117.00								39.00						107.00			117.00		39.00			
H5005	019	0	1	01	01	H5005_019_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.00	222.00								74.00						212.00			222.00		74.00			
H5005	019	0	1	01	01	H5005_019_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5005	019	0	1	01	01	H5005_019_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5005	024	0	1	01	01	H5005_024_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	60.00	180.00								60.00						170.00			180.00		60.00			
H5005	024	0	1	01	01	H5005_024_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  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	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5005	024	0	1	01	01	H5005_024_0	5	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00	1	1	
H5005	024	0	1	01	01	H5005_024_0	5	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H5005	024	0	1	01	01	H5005_024_0	5	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H5005	024	0	1	01	01	H5005_024_0	5	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H5006	016	1	1	09	04	H5006_016_1	5	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5006	016	1	1	09	04	H5006_016_1	5	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	36.00	108.00									36.00		72.00								36.00			
H5006	016	1	1	09	04	H5006_016_1	5	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5006	016	2	1	09	04	H5006_016_2	5	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5006	016	2	1	09	04	H5006_016_2	5	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5006	016	2	1	09	04	H5006_016_2	5	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	36.00	108.00									36.00		72.00								36.00			
H5006	016	3	1	09	04	H5006_016_3	5	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5006	016	3	1	09	04	H5006_016_3	5	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5006	016	3	1	09	04	H5006_016_3	5	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	36.00	108.00									36.00		72.00								36.00			
H5006	017	1	1	09	04	H5006_017_1	5	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5006	017	1	1	09	04	H5006_017_1	5	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
H5006	017	1	1	09	04	H5006_017_1	5	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5006	017	2	1	09	04	H5006_017_2	5	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
H5006	017	2	1	09	04	H5006_017_2	5	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5006	017	2	1	09	04	H5006_017_2	5	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5006	017	3	1	09	04	H5006_017_3	5	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
H5006	017	3	1	09	04	H5006_017_3	5	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5006	017	3	1	09	04	H5006_017_3	5	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5008	004	0	1	01	01	H5008_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H5008	004	0	1	01	01	H5008_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5008	004	0	1	01	01	H5008_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H5008	004	0	1	01	01	H5008_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5008	006	0	1	01	01	H5008_006_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5008	006	0	1	01	01	H5008_006_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H5008	006	0	1	01	01	H5008_006_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5008	006	0	1	01	01	H5008_006_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H5009	002	0	1	04	01	H5009_002_0	4	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H5009	002	0	1	04	01	H5009_002_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H5009	002	0	1	04	01	H5009_002_0	4	1	3	1	Generic	001000		2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H5009	002	0	1	04	01	H5009_002_0	4	4	3	1	Miscellaneous Injectables	110001		2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	26									26		26									26	Miscellaneous Injectables																								
H5009	002	0	1	04	01	H5009_002_0	4	5	3	1	Specialty	110001		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	26									26		26									26	Specialty																								
H5009	004	0	1	04	01	H5009_004_0	5	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
H5009	004	0	1	04	01	H5009_004_0	5	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
H5009	004	0	1	04	01	H5009_004_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5009	004	0	1	04	01	H5009_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5009	004	0	1	04	01	H5009_004_0	5	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
H5009	004	0	1	04	01	H5009_004_0	5	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5009	004	0	1	04	01	H5009_004_0	5	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H5009	004	0	1	04	01	H5009_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H5009	004	0	1	04	01	H5009_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H5009	004	0	1	04	01	H5009_004_0	5	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
H5010	002	0	1	04	01	H5010_002_0	4	4	3	1	Miscellaneous Injectables	110001		2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	26									26		26									26	Miscellaneous Injectables																								
H5010	002	0	1	04	01	H5010_002_0	4	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H5010	002	0	1	04	01	H5010_002_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H5010	002	0	1	04	01	H5010_002_0	4	1	3	1	Generic	001000		2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H5010	002	0	1	04	01	H5010_002_0	4	5	3	1	Specialty	110001		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	26									26		26									26	Specialty																								
H5010	004	0	1	04	01	H5010_004_0	5	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
H5010	004	0	1	04	01	H5010_004_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5010	004	0	1	04	01	H5010_004_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5010	004	0	1	04	01	H5010_004_0	5	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
H5010	004	0	1	04	01	H5010_004_0	5	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
H5010	004	0	1	04	01	H5010_004_0	5	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
H5010	004	0	1	04	01	H5010_004_0	5	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5010	004	0	1	04	01	H5010_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
H5010	004	0	1	04	01	H5010_004_0	5	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H5010	004	0	1	04	01	H5010_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
H5041	001	0	1	04	01	H5041_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5041	001	0	1	04	01	H5041_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H5041	001	0	1	04	01	H5041_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5041	001	0	1	04	01	H5041_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5041	001	0	1	04	01	H5041_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H5041	001	0	1	04	01	H5041_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5041	001	0	1	04	01	H5041_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5041	002	0	1	04	01	H5041_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5041	002	0	1	04	01	H5041_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5041	002	0	1	04	01	H5041_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5041	002	0	1	04	01	H5041_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5041	002	0	1	04	01	H5041_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5041	002	0	1	04	01	H5041_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5041	002	0	1	04	01	H5041_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5041	002	0	1	04	01	H5041_002_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5042	001	0	1	04	01	H5042_001_0	7	4	4	3	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand																								Tier 4 Formulary Non-Preferred Brand		Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand																						2		
H5042	001	0	1	04	01	H5042_001_0	7	5	4	3	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty																								Tier 5 Formulary Specialty		Tier 5 Formulary Specialty																						Tier 5 Formulary Specialty																						2		
H5042	001	0	1	04	01	H5042_001_0	7	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2	2	Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3 Formulary Preferred Brand	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				35.00	105.00		40.00	120.00		40.00		35.00	70.00								40.00			
H5042	001	0	1	04	01	H5042_001_0	7	4	4	1	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4 Formulary Non-Preferred Brand	2	Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand				70.00	210.00		75.00	225.00		75.00		70.00	140.00								75.00			
H5042	001	0	1	04	01	H5042_001_0	7	5	4	1	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty	100010010010100000000				30			30			30		30									31		Tier 5 Formulary Specialty	1	Tier 5 Formulary Specialty				30			30			30		30									30	Tier 5 Formulary Specialty																								
H5042	001	0	1	04	01	H5042_001_0	7	1	4	3	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00	1	1	
H5042	001	0	1	04	01	H5042_001_0	7	1	4	1	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred 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	7	2	4	1	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred 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	7	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																						2		
H5042	001	0	1	04	01	H5042_001_0	7	2	4	3	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00	1	1	
H5042	005	0	1	04	01	H5042_005_0	11	1	4	1	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred 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	11	5	4	1	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty	100010010010100000000				30			30			30		30									31		Tier 5 Formulary Specialty	1	Tier 5 Formulary Specialty				25			25			25		25									25	Tier 5 Formulary Specialty																								
H5042	005	0	1	04	01	H5042_005_0	11	4	4	1	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4 Formulary Non-Preferred Brand	2	Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand				70.00	210.00		75.00	225.00		75.00		70.00	140.00								75.00			
H5042	005	0	1	04	01	H5042_005_0	11	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2	2	Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3 Formulary Preferred Brand	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				35.00	105.00		40.00	120.00		40.00		35.00	70.00								40.00			
H5042	005	0	1	04	01	H5042_005_0	11	2	4	1	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred 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	9	5	4	3	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty																								Tier 5 Formulary Specialty		Tier 5 Formulary Specialty																						Tier 5 Formulary Specialty																						2		
H5042	007	0	1	04	01	H5042_007_0	9	1	4	1	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred 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	9	2	4	1	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred 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	9	3	4	1	Tier 3 Formulary Preferred Brand	000001	1	2	2	Tier 3 Formulary Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3 Formulary Preferred Brand	2	Tier 3 Formulary Preferred Brand																						Tier 3 Formulary Preferred Brand				35.00	105.00		40.00	120.00		40.00		35.00	70.00								40.00			
H5042	007	0	1	04	01	H5042_007_0	9	4	4	1	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4 Formulary Non-Preferred Brand	2	Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand				70.00	210.00		75.00	225.00		75.00		70.00	140.00								75.00			
H5042	007	0	1	04	01	H5042_007_0	9	5	4	1	Tier 5 Formulary Specialty	010010	1	1	2	Tier 5 Formulary Specialty	100010010010100000000				30			30			30		30									31		Tier 5 Formulary Specialty	1	Tier 5 Formulary Specialty				30			30			30		30									30	Tier 5 Formulary Specialty																								
H5042	007	0	1	04	01	H5042_007_0	9	1	4	3	Tier 1 Formulary Preferred Generics	001000	1	2	2	Tier 1 Formulary Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1 Formulary Preferred Generics	2	Tier 1 Formulary Preferred Generics																						Tier 1 Formulary Preferred Generics				2.00	6.00		3.00	9.00		3.00		2.00	4.00								3.00	1	1	
H5042	007	0	1	04	01	H5042_007_0	9	2	4	3	Tier 2 Formulary Non-Preferred Generics	000100	1	2	2	Tier 2 Formulary Non-Preferred Generics	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2 Formulary Non-Preferred Generics	2	Tier 2 Formulary Non-Preferred Generics																						Tier 2 Formulary Non-Preferred Generics				4.00	12.00		5.00	15.00		5.00		4.00	8.00								5.00	1	1	
H5042	007	0	1	04	01	H5042_007_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																						2		
H5042	007	0	1	04	01	H5042_007_0	9	4	4	3	Tier 4 Formulary Non-Preferred Brand	100000	1	2	1	Tier 4 Formulary Non-Preferred Brand																								Tier 4 Formulary Non-Preferred Brand		Tier 4 Formulary Non-Preferred Brand																						Tier 4 Formulary Non-Preferred Brand																						2		
H5050	004	0	1	01	01	H5050_004_0	8	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																								
H5050	004	0	1	01	01	H5050_004_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	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	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	45.00								15.00			
H5050	009	0	1	01	01	H5050_009_0	8	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	14.00	42.00								14.00		14.00	42.00								14.00			
H5050	009	0	1	01	01	H5050_009_0	8	1	2	1	Prefered Generic	001000		2	2	Prefered Generic	111000000010110000000	30	90								30		30	90								31	2	Prefered Generic	2	Prefered Generic																						Prefered Generic	4.00	12.00								4.00		4.00	12.00								4.00			
H5050	009	0	1	01	01	H5050_009_0	8	3	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																								
H5050	012	0	1	01	01	H5050_012_0	6	1	4	3	Prefered Generics	001000	1	2	2	Prefered Generics	111000000010110000000	30	90								30		30	90								31	2	Prefered Generics	2	Prefered Generics																						Prefered Generics	10.00	30.00								10.00		10.00	30.00								10.00	1	1	
H5050	012	0	1	01	01	H5050_012_0	6	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																								
H5050	012	0	1	01	01	H5050_012_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	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	1	4	1	Prefered Generics	001000	1	2	2	Prefered Generics	111000000010110000000	30	90								30		30	90								31	2	Prefered Generics	2	Prefered Generics																						Prefered Generics	10.00	30.00								10.00		10.00	30.00								10.00			
H5050	012	0	1	01	01	H5050_012_0	6	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
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																						2		
H5050	013	0	1	01	01	H5050_013_0	8	3	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	50								50	Non-Preferred																								
H5050	013	0	1	01	01	H5050_013_0	8	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	17.00	51.00								17.00		17.00	51.00								17.00			
H5050	013	0	1	01	01	H5050_013_0	8	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00		6.00	18.00								6.00			
H5087	001	0	1	01	01	H5087_001_0	11	4	4	3	Specialty	111111	3	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5087	001	0	1	01	01	H5087_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																						2		
H5087	001	0	1	01	01	H5087_001_0	11	2	4	3	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00		40.00	80.00								40.00	1	1	
H5087	001	0	1	01	01	H5087_001_0	11	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5087	001	0	1	01	01	H5087_001_0	11	4	4	1	Specialty	111111	3	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H5087	001	0	1	01	01	H5087_001_0	11	3	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	160.00								80.00		80.00	160.00								80.00			
H5087	001	0	1	01	01	H5087_001_0	11	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Preferred Generic	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	11	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	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	16	2	4	3	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	40.00								40.00		40.00	80.00								40.00	1	1	
H5087	002	0	1	01	01	H5087_002_0	16	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5087	002	0	1	01	01	H5087_002_0	16	4	4	3	Specialty	101001	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5087	002	0	1	01	01	H5087_002_0	16	1	4	1	Preferred Generics	001000	1	2	2	Preferred Generics	111000000010110000000	30	90								30		30	90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00			
H5087	002	0	1	01	01	H5087_002_0	16	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	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	16	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	160.00								80.00		80.00	160.00								80.00			
H5087	002	0	1	01	01	H5087_002_0	16	4	4	1	Specialty	101001	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H5087	002	0	1	01	01	H5087_002_0	16	1	4	3	Preferred Generics	001000	1	2	2	Preferred Generics	111000000010110000000	30	90								30		30	90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5087	005	0	1	01	01	H5087_005_0	15	4	4	3	Specialty	111111	3	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5087	005	0	1	01	01	H5087_005_0	15	3	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5087	005	0	1	01	01	H5087_005_0	15	2	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5087	005	0	1	01	01	H5087_005_0	15	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00		5.00	10.00								5.00	1	1	
H5087	005	0	1	01	01	H5087_005_0	15	4	4	1	Specialty	111111	3	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H5087	005	0	1	01	01	H5087_005_0	15	3	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	160.00								80.00		80.00	160.00								80.00			
H5087	005	0	1	01	01	H5087_005_0	15	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00		25.00	50.00								25.00			
H5087	005	0	1	01	01	H5087_005_0	15	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	10.00								5.00		5.00	10.00								5.00			
H5106	013	0	1	04	01	H5106_013_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H5106	013	0	1	04	01	H5106_013_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H5106	013	0	1	04	01	H5106_013_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H5106	013	0	1	04	01	H5106_013_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5106	014	0	1	04	01	H5106_014_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00	1	1	
H5106	014	0	1	04	01	H5106_014_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5106	014	0	1	04	01	H5106_014_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5106	014	0	1	04	01	H5106_014_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5106	014	0	1	04	01	H5106_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																						2		
H5106	014	0	1	04	01	H5106_014_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H5106	014	0	1	04	01	H5106_014_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H5106	014	0	1	04	01	H5106_014_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00			
H5106	015	0	1	04	01	H5106_015_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H5106	015	0	1	04	01	H5106_015_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H5106	015	0	1	04	01	H5106_015_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H5106	015	0	1	04	01	H5106_015_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5106	016	0	1	04	01	H5106_016_0	5	4	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5106	016	0	1	04	01	H5106_016_0	5	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5106	016	0	1	04	01	H5106_016_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5106	016	0	1	04	01	H5106_016_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00	1	1	
H5106	016	0	1	04	01	H5106_016_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00		15.00	15.00								6.00			
H5106	016	0	1	04	01	H5106_016_0	5	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5106	016	0	1	04	01	H5106_016_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		200.00	200.00								80.00			
H5106	016	0	1	04	01	H5106_016_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
H5151	002	0	1	01	01	H5151_002_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5151	002	0	1	01	01	H5151_002_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H5151	002	0	1	01	01	H5151_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																								
H5151	002	0	1	01	01	H5151_002_0	3	4	4	1	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	20									20		20									20	Specialty																								
H5151	002	0	1	01	01	H5151_002_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H5151	002	0	1	01	01	H5151_002_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5151	002	0	1	01	01	H5151_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5151	002	0	1	01	01	H5151_002_0	3	4	4	3	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	2	Specialty																						Specialty	10.00									10.00		10.00									10.00	1	2	01000000
H5162	002	0	1	04	01	H5162_002_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5162	002	0	1	04	01	H5162_002_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5162	002	0	1	04	01	H5162_002_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
H5162	004	0	1	04	01	H5162_004_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5162	004	0	1	04	01	H5162_004_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	35.00	105.00									35.00		70.00								35.00			
H5162	004	0	1	04	01	H5162_004_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5162	006	0	1	04	01	H5162_006_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
H5162	006	0	1	04	01	H5162_006_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5162	006	0	1	04	01	H5162_006_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5211	002	0	1	02	01	H5211_002_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								34	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H5211	002	0	1	02	01	H5211_002_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00			
H5211	002	0	1	02	01	H5211_002_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H5211	002	0	1	02	01	H5211_002_0	5	4	4	1	Tier 4	000001	1	1	2	Tier 4	110000000010100000000	30									30		30									34		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H5211	004	0	1	02	01	H5211_004_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H5211	004	0	1	02	01	H5211_004_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00			
H5211	004	0	1	02	01	H5211_004_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								34	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H5211	004	0	1	02	01	H5211_004_0	5	4	4	1	Tier 4	000001	1	1	2	Tier 4	110000000010100000000	30									30		30									34		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H5211	005	0	1	02	01	H5211_005_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H5211	005	0	1	02	01	H5211_005_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								34	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
H5211	005	0	1	02	01	H5211_005_0	5	4	4	1	Tier 4	000001	1	1	2	Tier 4	110000000010100000000	30									30		30									34		Tier 4	1	Tier 4	33									33		33									33	Tier 4																								
H5211	005	0	1	02	01	H5211_005_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			90.00								30.00			
H5214	003	0	1	04	01	H5214_003_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5214	003	0	1	04	01	H5214_003_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5214	003	0	1	04	01	H5214_003_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5214	003	0	1	04	01	H5214_003_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5214	003	0	1	04	01	H5214_003_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5214	003	0	1	04	01	H5214_003_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5214	004	0	1	04	01	H5214_004_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5214	004	0	1	04	01	H5214_004_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5214	004	0	1	04	01	H5214_004_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5214	004	0	1	04	01	H5214_004_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5214	004	0	1	04	01	H5214_004_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5214	004	0	1	04	01	H5214_004_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5214	004	0	1	04	01	H5214_004_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5214	004	0	1	04	01	H5214_004_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5214	008	0	1	04	01	H5214_008_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5214	008	0	1	04	01	H5214_008_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5214	008	0	1	04	01	H5214_008_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5214	008	0	1	04	01	H5214_008_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5214	008	0	1	04	01	H5214_008_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5214	008	0	1	04	01	H5214_008_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5214	008	0	1	04	01	H5214_008_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5214	008	0	1	04	01	H5214_008_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5214	009	0	1	04	01	H5214_009_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5214	009	0	1	04	01	H5214_009_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5214	009	0	1	04	01	H5214_009_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5214	009	0	1	04	01	H5214_009_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5214	009	0	1	04	01	H5214_009_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5214	009	0	1	04	01	H5214_009_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5214	009	0	1	04	01	H5214_009_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5214	009	0	1	04	01	H5214_009_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5214	010	0	1	04	01	H5214_010_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5214	010	0	1	04	01	H5214_010_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5214	010	0	1	04	01	H5214_010_0	5	3	4	3	Non-Preferred Brand	000011	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5214	010	0	1	04	01	H5214_010_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5214	010	0	1	04	01	H5214_010_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5214	010	0	1	04	01	H5214_010_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5214	010	0	1	04	01	H5214_010_0	5	3	4	1	Non-Preferred Brand	000011	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5214	010	0	1	04	01	H5214_010_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5215	002	0	1	04	01	H5215_002_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	19.00								7.00		7.00	19.00								7.00			
H5215	002	0	1	04	01	H5215_002_0	4	3	4	1	Preferred Brand	010001	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	26.00	68.00								26.00		26.00	68.00								26.00			
H5215	002	0	1	04	01	H5215_002_0	4	4	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	53.00	150.00								53.00		53.00	150.00								53.00			
H5215	002	0	1	04	01	H5215_002_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H5215	002	0	1	04	01	H5215_002_0	4	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	7.00	19.00								7.00		7.00	19.00								7.00			
H5215	002	0	1	04	01	H5215_002_0	4	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	9.00	24.00								9.00		9.00	24.00								9.00	1	1	
H5215	002	0	1	04	01	H5215_002_0	4	3	4	3	Preferred Brand	010001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5215	002	0	1	04	01	H5215_002_0	4	4	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5215	002	0	1	04	01	H5215_002_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5215	002	0	1	04	01	H5215_002_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	24.00								9.00		9.00	24.00								9.00	1	1	
H5215	005	0	1	04	01	H5215_005_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	19.00								7.00		7.00	19.00								7.00			
H5215	005	0	1	04	01	H5215_005_0	4	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	7.00	19.00								7.00		7.00	19.00								7.00			
H5215	005	0	1	04	01	H5215_005_0	4	3	4	1	Preferred Brand	010001	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	26.00	68.00								26.00		26.00	68.00								26.00			
H5215	005	0	1	04	01	H5215_005_0	4	4	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	53.00	150.00								53.00		53.00	150.00								53.00			
H5215	005	0	1	04	01	H5215_005_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H5215	005	0	1	04	01	H5215_005_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	24.00								9.00		9.00	24.00								9.00	1	1	
H5215	005	0	1	04	01	H5215_005_0	4	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	9.00	24.00								9.00		9.00	24.00								9.00	1	1	
H5215	005	0	1	04	01	H5215_005_0	4	3	4	3	Preferred Brand	010001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5215	005	0	1	04	01	H5215_005_0	4	4	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5215	005	0	1	04	01	H5215_005_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5215	007	0	1	04	01	H5215_007_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5215	007	0	1	04	01	H5215_007_0	5	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5215	007	0	1	04	01	H5215_007_0	5	3	4	1	Preferred Brand	010001	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00		0.00	0.00								0.00			
H5215	007	0	1	04	01	H5215_007_0	5	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H5215	007	0	1	04	01	H5215_007_0	5	4	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	94.00	282.00								94.00		94.00	282.00								94.00			
H5215	008	0	1	04	01	H5215_008_0	6	4	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	53.00	150.00								53.00		53.00	150.00								53.00			
H5215	008	0	1	04	01	H5215_008_0	6	3	4	1	Preferred Brand	010001	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	26.00	68.00								26.00		26.00	68.00								26.00			
H5215	008	0	1	04	01	H5215_008_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	31									31		31									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H5215	008	0	1	04	01	H5215_008_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	19.00								7.00		7.00	19.00								7.00			
H5215	008	0	1	04	01	H5215_008_0	6	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010110000000	31	90								31		31	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred 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	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H5216	001	0	1	04	01	H5216_001_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5216	001	0	1	04	01	H5216_001_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5216	001	0	1	04	01	H5216_001_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5216	001	0	1	04	01	H5216_001_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5216	001	0	1	04	01	H5216_001_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H5216	001	0	1	04	01	H5216_001_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H5216	003	0	1	04	01	H5216_003_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H5216	003	0	1	04	01	H5216_003_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5216	003	0	1	04	01	H5216_003_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5216	003	0	1	04	01	H5216_003_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5216	003	0	1	04	01	H5216_003_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5216	003	0	1	04	01	H5216_003_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H5216	003	0	1	04	01	H5216_003_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5216	003	0	1	04	01	H5216_003_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5216	006	0	1	04	01	H5216_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5216	006	0	1	04	01	H5216_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5216	006	0	1	04	01	H5216_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H5216	006	0	1	04	01	H5216_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5216	006	0	1	04	01	H5216_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5216	006	0	1	04	01	H5216_006_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5216	006	0	1	04	01	H5216_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H5216	006	0	1	04	01	H5216_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5216	007	0	1	04	01	H5216_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5216	007	0	1	04	01	H5216_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5216	007	0	1	04	01	H5216_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5216	007	0	1	04	01	H5216_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5216	007	0	1	04	01	H5216_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5216	007	0	1	04	01	H5216_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5216	007	0	1	04	01	H5216_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5216	007	0	1	04	01	H5216_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5216	008	0	1	04	01	H5216_008_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5216	008	0	1	04	01	H5216_008_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5216	008	0	1	04	01	H5216_008_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5216	008	0	1	04	01	H5216_008_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5216	008	0	1	04	01	H5216_008_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5216	008	0	1	04	01	H5216_008_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5216	008	0	1	04	01	H5216_008_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5216	008	0	1	04	01	H5216_008_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5253	004	0	1	02	01	H5253_004_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5253	004	0	1	02	01	H5253_004_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H5253	004	0	1	02	01	H5253_004_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5253	004	0	1	02	01	H5253_004_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5253	011	0	1	02	01	H5253_011_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5253	011	0	1	02	01	H5253_011_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H5253	011	0	1	02	01	H5253_011_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H5253	011	0	1	02	01	H5253_011_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5253	027	0	1	02	01	H5253_027_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H5253	027	0	1	02	01	H5253_027_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5253	027	0	1	02	01	H5253_027_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H5253	027	0	1	02	01	H5253_027_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5253	028	0	1	02	01	H5253_028_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5253	028	0	1	02	01	H5253_028_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						206.00			216.00		72.00			
H5253	028	0	1	02	01	H5253_028_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	38.00	114.00								38.00						104.00			114.00		38.00			
H5253	028	0	1	02	01	H5253_028_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5253	029	0	1	02	01	H5253_029_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5253	029	0	1	02	01	H5253_029_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H5253	029	0	1	02	01	H5253_029_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H5253	029	0	1	02	01	H5253_029_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5262	001	0	1	01	01	H5262_001_0	3	2	3	1	Tier 2 - Formulary Preferred Brand Drugs	000001		2	2	Tier 2 - Formulary Preferred Brand Drugs	111000000010000000000	30	90								30											31	1	Tier 2 - Formulary Preferred Brand Drugs	2	Tier 2 - Formulary Preferred Brand Drugs																						Tier 2 - Formulary Preferred Brand Drugs	24.00	72.00								24.00											24.00			
H5262	001	0	1	01	01	H5262_001_0	3	4	3	1	Tier 4 - Specialty High Cost Drugs	010010		1	2	Tier 4 - Specialty High Cost Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty High Cost Drugs	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	3	3	3	1	Tier 3 - Formulary Non-Preferred Brand Drugs	100000		2	1	Tier 3 - Formulary Non-Preferred Brand Drugs	111000000010000000000	30	90								30											31	1	Tier 3 - Formulary Non-Preferred Brand Drugs	2	Tier 3 - Formulary Non-Preferred Brand Drugs																						Tier 3 - Formulary Non-Preferred Brand Drugs	80.00	240.00								80.00											80.00			
H5262	001	0	1	01	01	H5262_001_0	3	1	3	1	Tier 1 - Generic Drugs	010000		2	2	Tier 1 - Generic Drugs	111000000010000000000	30	90								30											31	1	Tier 1 - Generic Drugs	2	Tier 1 - Generic Drugs																						Tier 1 - Generic Drugs	9.00	27.00								9.00											9.00			
H5262	003	0	1	01	01	H5262_003_0	3	2	3	1	Tier 2 - Formulary Preferred Brand Drugs	000001		2	2	Tier 2 - Formulary Preferred Brand Drugs	111000000010000000000	30	90								30											31	1	Tier 2 - Formulary Preferred Brand Drugs	2	Tier 2 - Formulary Preferred Brand Drugs																						Tier 2 - Formulary Preferred Brand Drugs	32.00	96.00								32.00											32.00			
H5262	003	0	1	01	01	H5262_003_0	3	1	3	1	Tier 1 - Generic Drugs	010000		2	2	Tier 1 - Generic Drugs	111000000010000000000	30	90								30											31	1	Tier 1 - Generic Drugs	2	Tier 1 - Generic Drugs																						Tier 1 - Generic Drugs	9.00	27.00								9.00											9.00			
H5262	003	0	1	01	01	H5262_003_0	3	4	3	1	Tier 4 - Specialty High Cost Drugs	010010		1	2	Tier 4 - Specialty High Cost Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty High Cost Drugs	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	3	3	3	1	Tier 3 - Formulary Non-Preferred Brand Drugs	100000		2	1	Tier 3 - Formulary Non-Preferred Brand Drugs	111000000010000000000	30	90								30											31	1	Tier 3 - Formulary Non-Preferred Brand Drugs	2	Tier 3 - Formulary Non-Preferred Brand Drugs																						Tier 3 - Formulary Non-Preferred Brand Drugs	87.00	261.00								87.00											87.00			
H5291	001	0	1	01	01	H5291_001_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H5291	001	0	1	01	01	H5291_001_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H5291	001	0	1	01	01	H5291_001_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5291	001	0	1	01	01	H5291_001_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5291	001	0	1	01	01	H5291_001_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H5291	001	0	1	01	01	H5291_001_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H5291	001	0	1	01	01	H5291_001_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5291	001	0	1	01	01	H5291_001_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5294	001	0	1	01	01	H5294_001_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	2	Generic																						Generic	0.00	0.00									0.00		0.00								0.00			
H5294	001	0	1	01	01	H5294_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	30	90									29		90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	95.00									95.00		95.00								95.00			
H5294	001	0	1	01	01	H5294_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	45.00									45.00		45.00								45.00			
H5294	001	0	1	01	01	H5294_001_0	7	4	4	1	Injectables	000001	1	2	1	Injectables	111000000001010000000	30	90									29		90								31	2	Injectables	2	Injectables																						Injectables	95.00	95.00									95.00		95.00								95.00			
H5302	003	0	1	02	01	H5302_003_0	10	1	4	1	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	4.00	12.00								4.00			10.00								4.00			
H5302	003	0	1	02	01	H5302_003_0	10	2	4	1	preferred brand	000001	1	2	2	preferred brand	111000000010010000000	30	90								30			90								31	2	preferred brand	2	preferred brand																						preferred brand	37.00	111.00								37.00			92.50								37.00			
H5302	003	0	1	02	01	H5302_003_0	10	3	4	1	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand	111000000010010000000	30	90								30			90								31	2	non-preferred generic/Non-preferred brand	2	non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand	69.00	207.00								69.00			207.00								69.00			
H5302	003	0	1	02	01	H5302_003_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H5302	003	0	1	02	01	H5302_003_0	10	1	4	3	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	4.00	12.00								4.00			10.00								4.00	1	1	
H5302	003	0	1	02	01	H5302_003_0	10	2	4	3	preferred brand	000001	1	2	2	preferred brand																								preferred brand		preferred brand																						preferred brand																						2		
H5302	003	0	1	02	01	H5302_003_0	10	3	4	3	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand																								non-preferred generic/Non-preferred brand		non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand																						2		
H5302	003	0	1	02	01	H5302_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																						2		
H5302	004	0	1	02	01	H5302_004_0	10	1	4	1	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	4.00	12.00								4.00			10.00								4.00			
H5302	004	0	1	02	01	H5302_004_0	10	2	4	1	preferred brand	000001	1	2	2	preferred brand	111000000010010000000	30	90								30			90								31	2	preferred brand	2	preferred brand																						preferred brand	36.00	108.00								36.00			90.00								36.00			
H5302	004	0	1	02	01	H5302_004_0	10	3	4	1	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand	111000000010010000000	30	90								30			90								31	2	non-preferred generic/Non-preferred brand	2	non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand	68.00	204.00								68.00			204.00								68.00			
H5302	004	0	1	02	01	H5302_004_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H5302	004	0	1	02	01	H5302_004_0	10	1	4	3	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	4.00	12.00								4.00			10.00								4.00	1	1	
H5302	004	0	1	02	01	H5302_004_0	10	2	4	3	preferred brand	000001	1	2	2	preferred brand																								preferred brand		preferred brand																						preferred brand																						2		
H5302	004	0	1	02	01	H5302_004_0	10	3	4	3	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand																								non-preferred generic/Non-preferred brand		non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand																						2		
H5302	004	0	1	02	01	H5302_004_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																						2		
H5302	005	0	1	02	01	H5302_005_0	8	1	4	3	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	3.00	9.00								3.00			7.50								3.00	1	1	
H5302	005	0	1	02	01	H5302_005_0	8	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
H5302	005	0	1	02	01	H5302_005_0	8	3	4	1	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand	111000000010010000000	30	90								30			90								31	2	non-preferred generic/Non-preferred brand	2	non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand	64.00	192.00								64.00			192.00								64.00			
H5302	005	0	1	02	01	H5302_005_0	8	2	4	1	preferred brand	000001	1	2	2	preferred brand	111000000010010000000	30	90								30			90								31	2	preferred brand	2	preferred brand																						preferred brand	34.00	102.00								34.00			85.00								34.00			
H5302	005	0	1	02	01	H5302_005_0	8	1	4	1	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	3.00	9.00								3.00			7.50								3.00			
H5302	005	0	1	02	01	H5302_005_0	8	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																						2		
H5302	005	0	1	02	01	H5302_005_0	8	2	4	3	preferred brand	000001	1	2	2	preferred brand																								preferred brand		preferred brand																						preferred brand																						2		
H5302	005	0	1	02	01	H5302_005_0	8	3	4	3	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand																								non-preferred generic/Non-preferred brand		non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand																						2		
H5302	006	0	1	02	01	H5302_006_0	10	3	4	3	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand																								non-preferred generic/Non-preferred brand		non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand																						2		
H5302	006	0	1	02	01	H5302_006_0	10	2	4	3	preferred brand	000001	1	2	2	preferred brand																								preferred brand		preferred brand																						preferred brand																						2		
H5302	006	0	1	02	01	H5302_006_0	10	1	4	3	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	4.00	12.00								4.00			10.00								4.00	1	1	
H5302	006	0	1	02	01	H5302_006_0	10	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H5302	006	0	1	02	01	H5302_006_0	10	3	4	1	non-preferred generic/Non-preferred brand	100100	1	2	1	non-preferred generic/Non-preferred brand	111000000010010000000	30	90								30			90								31	2	non-preferred generic/Non-preferred brand	2	non-preferred generic/Non-preferred brand																						non-preferred generic/Non-preferred brand	68.00	204.00								68.00			204.00								68.00			
H5302	006	0	1	02	01	H5302_006_0	10	2	4	1	preferred brand	000001	1	2	2	preferred brand	111000000010010000000	30	90								30			90								31	2	preferred brand	2	preferred brand																						preferred brand	36.00	108.00								36.00			90.00								36.00			
H5302	006	0	1	02	01	H5302_006_0	10	1	4	1	preferred generic	001000	3	2	2	preferred generic	111000000010010000000	30	90								30			90								31	2	preferred generic	2	preferred generic																						preferred generic	4.00	12.00								4.00			10.00								4.00			
H5302	006	0	1	02	01	H5302_006_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																						2		
H5378	004	0	1	04	01	H5378_004_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	004	0	1	04	01	H5378_004_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	004	0	1	04	01	H5378_004_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	004	0	1	04	01	H5378_004_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	005	0	1	04	01	H5378_005_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	005	0	1	04	01	H5378_005_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	005	0	1	04	01	H5378_005_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	005	0	1	04	01	H5378_005_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	010	0	1	04	01	H5378_010_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	010	0	1	04	01	H5378_010_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	010	0	1	04	01	H5378_010_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	010	0	1	04	01	H5378_010_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	010	0	1	04	01	H5378_010_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	010	0	1	04	01	H5378_010_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	010	0	1	04	01	H5378_010_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	010	0	1	04	01	H5378_010_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	011	0	1	04	01	H5378_011_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	011	0	1	04	01	H5378_011_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	011	0	1	04	01	H5378_011_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	011	0	1	04	01	H5378_011_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	011	0	1	04	01	H5378_011_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	011	0	1	04	01	H5378_011_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	011	0	1	04	01	H5378_011_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	011	0	1	04	01	H5378_011_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	016	0	1	04	01	H5378_016_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	016	0	1	04	01	H5378_016_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	016	0	1	04	01	H5378_016_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	016	0	1	04	01	H5378_016_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	017	0	1	04	01	H5378_017_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	017	0	1	04	01	H5378_017_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	017	0	1	04	01	H5378_017_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	017	0	1	04	01	H5378_017_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	061	0	1	04	01	H5378_061_0	8	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	061	0	1	04	01	H5378_061_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	061	0	1	04	01	H5378_061_0	8	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	061	0	1	04	01	H5378_061_0	8	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	092	0	1	04	01	H5378_092_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	092	0	1	04	01	H5378_092_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	092	0	1	04	01	H5378_092_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	092	0	1	04	01	H5378_092_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	092	0	1	04	01	H5378_092_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	092	0	1	04	01	H5378_092_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	092	0	1	04	01	H5378_092_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	092	0	1	04	01	H5378_092_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	154	0	1	04	01	H5378_154_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	154	0	1	04	01	H5378_154_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	154	0	1	04	01	H5378_154_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	154	0	1	04	01	H5378_154_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	175	0	1	04	01	H5378_175_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	175	0	1	04	01	H5378_175_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	175	0	1	04	01	H5378_175_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	175	0	1	04	01	H5378_175_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	176	0	1	04	01	H5378_176_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	176	0	1	04	01	H5378_176_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	176	0	1	04	01	H5378_176_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	176	0	1	04	01	H5378_176_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	177	0	1	04	01	H5378_177_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	177	0	1	04	01	H5378_177_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	177	0	1	04	01	H5378_177_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	177	0	1	04	01	H5378_177_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	178	0	1	04	01	H5378_178_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	178	0	1	04	01	H5378_178_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	178	0	1	04	01	H5378_178_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	178	0	1	04	01	H5378_178_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	179	0	1	04	01	H5378_179_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	179	0	1	04	01	H5378_179_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	179	0	1	04	01	H5378_179_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	179	0	1	04	01	H5378_179_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	180	0	1	04	01	H5378_180_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	180	0	1	04	01	H5378_180_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	180	0	1	04	01	H5378_180_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	180	0	1	04	01	H5378_180_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	181	0	1	04	01	H5378_181_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	181	0	1	04	01	H5378_181_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	181	0	1	04	01	H5378_181_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	181	0	1	04	01	H5378_181_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	181	0	1	04	01	H5378_181_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	181	0	1	04	01	H5378_181_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	181	0	1	04	01	H5378_181_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	181	0	1	04	01	H5378_181_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	182	0	1	04	01	H5378_182_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	182	0	1	04	01	H5378_182_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	182	0	1	04	01	H5378_182_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	182	0	1	04	01	H5378_182_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	182	0	1	04	01	H5378_182_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	182	0	1	04	01	H5378_182_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	182	0	1	04	01	H5378_182_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	182	0	1	04	01	H5378_182_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	183	0	1	04	01	H5378_183_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	183	0	1	04	01	H5378_183_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	183	0	1	04	01	H5378_183_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	183	0	1	04	01	H5378_183_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	183	0	1	04	01	H5378_183_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	183	0	1	04	01	H5378_183_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	183	0	1	04	01	H5378_183_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	183	0	1	04	01	H5378_183_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	184	0	1	04	01	H5378_184_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	184	0	1	04	01	H5378_184_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	184	0	1	04	01	H5378_184_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	184	0	1	04	01	H5378_184_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	184	0	1	04	01	H5378_184_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	184	0	1	04	01	H5378_184_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	184	0	1	04	01	H5378_184_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	184	0	1	04	01	H5378_184_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	185	0	1	04	01	H5378_185_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	185	0	1	04	01	H5378_185_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	185	0	1	04	01	H5378_185_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	185	0	1	04	01	H5378_185_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	185	0	1	04	01	H5378_185_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	185	0	1	04	01	H5378_185_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	185	0	1	04	01	H5378_185_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	185	0	1	04	01	H5378_185_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	186	0	1	04	01	H5378_186_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	186	0	1	04	01	H5378_186_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	186	0	1	04	01	H5378_186_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	186	0	1	04	01	H5378_186_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	186	0	1	04	01	H5378_186_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	186	0	1	04	01	H5378_186_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	186	0	1	04	01	H5378_186_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	186	0	1	04	01	H5378_186_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	187	0	1	04	01	H5378_187_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	187	0	1	04	01	H5378_187_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	187	0	1	04	01	H5378_187_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	187	0	1	04	01	H5378_187_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	188	0	1	04	01	H5378_188_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5378	188	0	1	04	01	H5378_188_0	5	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5378	188	0	1	04	01	H5378_188_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5378	188	0	1	04	01	H5378_188_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5378	188	0	1	04	01	H5378_188_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	188	0	1	04	01	H5378_188_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	188	0	1	04	01	H5378_188_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	188	0	1	04	01	H5378_188_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	189	0	1	04	01	H5378_189_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	189	0	1	04	01	H5378_189_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	189	0	1	04	01	H5378_189_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	189	0	1	04	01	H5378_189_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	190	0	1	04	01	H5378_190_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	190	0	1	04	01	H5378_190_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	190	0	1	04	01	H5378_190_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	190	0	1	04	01	H5378_190_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	191	0	1	04	01	H5378_191_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	191	0	1	04	01	H5378_191_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	191	0	1	04	01	H5378_191_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	191	0	1	04	01	H5378_191_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	192	0	1	04	01	H5378_192_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	192	0	1	04	01	H5378_192_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	192	0	1	04	01	H5378_192_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	192	0	1	04	01	H5378_192_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	193	0	1	04	01	H5378_193_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	193	0	1	04	01	H5378_193_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	193	0	1	04	01	H5378_193_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	193	0	1	04	01	H5378_193_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	194	0	1	04	01	H5378_194_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	194	0	1	04	01	H5378_194_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	194	0	1	04	01	H5378_194_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	194	0	1	04	01	H5378_194_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5378	195	0	1	04	01	H5378_195_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5378	195	0	1	04	01	H5378_195_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5378	195	0	1	04	01	H5378_195_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5378	195	0	1	04	01	H5378_195_0	4	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	007	0	1	01	01	H5402_007_0	5	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5402	007	0	1	01	01	H5402_007_0	5	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	30.00								15.00			
H5402	007	0	1	01	01	H5402_007_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5402	007	0	1	01	01	H5402_007_0	5	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	007	0	1	01	01	H5402_007_0	5	5	4	3	Specialty	101100	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5402	007	0	1	01	01	H5402_007_0	5	1	4	3	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H5402	007	0	1	01	01	H5402_007_0	5	2	4	3	Preferred Brand	000101	3	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5402	007	0	1	01	01	H5402_007_0	5	3	4	3	Brand	100010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5402	007	0	1	01	01	H5402_007_0	5	4	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5402	007	0	1	01	01	H5402_007_0	5	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	032	0	1	01	01	H5402_032_0	4	5	4	3	Specialty	101100	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5402	032	0	1	01	01	H5402_032_0	4	4	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5402	032	0	1	01	01	H5402_032_0	4	3	4	3	Brand	100010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5402	032	0	1	01	01	H5402_032_0	4	2	4	3	Preferred Brand	000101	3	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5402	032	0	1	01	01	H5402_032_0	4	1	4	3	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H5402	032	0	1	01	01	H5402_032_0	4	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	032	0	1	01	01	H5402_032_0	4	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	032	0	1	01	01	H5402_032_0	4	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5402	032	0	1	01	01	H5402_032_0	4	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	30.00								15.00			
H5402	032	0	1	01	01	H5402_032_0	4	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5402	035	0	1	01	01	H5402_035_0	5	3	4	3	Brand	100010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5402	035	0	1	01	01	H5402_035_0	5	2	4	3	Preferred Brand	000101	3	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5402	035	0	1	01	01	H5402_035_0	5	1	4	3	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H5402	035	0	1	01	01	H5402_035_0	5	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	035	0	1	01	01	H5402_035_0	5	4	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5402	035	0	1	01	01	H5402_035_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5402	035	0	1	01	01	H5402_035_0	5	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	30.00								15.00			
H5402	035	0	1	01	01	H5402_035_0	5	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5402	035	0	1	01	01	H5402_035_0	5	5	4	3	Specialty	101100	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5402	035	0	1	01	01	H5402_035_0	5	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	036	0	1	01	01	H5402_036_0	6	5	4	3	Specialty	101100	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5402	036	0	1	01	01	H5402_036_0	6	4	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5402	036	0	1	01	01	H5402_036_0	6	3	4	3	Brand	100010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5402	036	0	1	01	01	H5402_036_0	6	2	4	3	Preferred Brand	000101	3	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5402	036	0	1	01	01	H5402_036_0	6	1	4	3	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H5402	036	0	1	01	01	H5402_036_0	6	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	036	0	1	01	01	H5402_036_0	6	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	036	0	1	01	01	H5402_036_0	6	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5402	036	0	1	01	01	H5402_036_0	6	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	30.00								15.00			
H5402	036	0	1	01	01	H5402_036_0	6	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5402	038	0	1	01	01	H5402_038_0	5	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	038	0	1	01	01	H5402_038_0	5	1	4	3	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00	1	1	
H5402	038	0	1	01	01	H5402_038_0	5	2	4	3	Preferred Brand	000101	3	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5402	038	0	1	01	01	H5402_038_0	5	3	4	3	Brand	100010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5402	038	0	1	01	01	H5402_038_0	5	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	038	0	1	01	01	H5402_038_0	5	5	4	3	Specialty	101100	3	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5402	038	0	1	01	01	H5402_038_0	5	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00			
H5402	038	0	1	01	01	H5402_038_0	5	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	40.00								20.00			
H5402	038	0	1	01	01	H5402_038_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	50.00	150.00								50.00											50.00			
H5402	038	0	1	01	01	H5402_038_0	5	4	4	3	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5402	039	0	1	01	01	H5402_039_0	7	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5402	039	0	1	01	01	H5402_039_0	7	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	039	0	1	01	01	H5402_039_0	7	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5402	039	0	1	01	01	H5402_039_0	7	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00			
H5402	039	0	1	01	01	H5402_039_0	7	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	30.00								15.00			
H5402	041	0	1	01	01	H5402_041_0	5	4	4	1	Non-Preferred Brand	100000	3	2	2	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	25									25											25	Non-Preferred Brand																								
H5402	041	0	1	01	01	H5402_041_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010000000000	30	90								30											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5402	041	0	1	01	01	H5402_041_0	5	2	4	1	Preferred Brand	000101	3	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	45.00								15.00		15.00	30.00								15.00			
H5402	041	0	1	01	01	H5402_041_0	5	1	4	1	Generic	001000	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5402	041	0	1	01	01	H5402_041_0	5	5	4	1	Specialty	101100	3	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5404	001	0	1	01	01	H5404_001_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	001	0	1	01	01	H5404_001_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	001	0	1	01	01	H5404_001_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	001	0	1	01	01	H5404_001_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	001	0	1	01	01	H5404_001_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	002	0	1	01	01	H5404_002_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	002	0	1	01	01	H5404_002_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	002	0	1	01	01	H5404_002_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	002	0	1	01	01	H5404_002_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	002	0	1	01	01	H5404_002_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	003	0	1	01	01	H5404_003_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	003	0	1	01	01	H5404_003_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	003	0	1	01	01	H5404_003_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	003	0	1	01	01	H5404_003_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	003	0	1	01	01	H5404_003_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	004	0	1	01	01	H5404_004_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	004	0	1	01	01	H5404_004_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	004	0	1	01	01	H5404_004_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	004	0	1	01	01	H5404_004_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	004	0	1	01	01	H5404_004_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	013	0	1	01	01	H5404_013_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	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	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	013	0	1	01	01	H5404_013_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	013	0	1	01	01	H5404_013_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	013	0	1	01	01	H5404_013_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	016	0	1	01	01	H5404_016_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	016	0	1	01	01	H5404_016_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	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	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	016	0	1	01	01	H5404_016_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	016	0	1	01	01	H5404_016_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	022	0	1	01	01	H5404_022_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	022	0	1	01	01	H5404_022_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	022	0	1	01	01	H5404_022_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	022	0	1	01	01	H5404_022_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	022	0	1	01	01	H5404_022_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	025	0	1	01	01	H5404_025_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	025	0	1	01	01	H5404_025_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	025	0	1	01	01	H5404_025_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	025	0	1	01	01	H5404_025_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	025	0	1	01	01	H5404_025_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	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	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	028	0	1	01	01	H5404_028_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	028	0	1	01	01	H5404_028_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	028	0	1	01	01	H5404_028_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	028	0	1	01	01	H5404_028_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	034	0	1	01	01	H5404_034_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	034	0	1	01	01	H5404_034_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	034	0	1	01	01	H5404_034_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	034	0	1	01	01	H5404_034_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	034	0	1	01	01	H5404_034_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	037	0	1	01	01	H5404_037_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	037	0	1	01	01	H5404_037_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	037	0	1	01	01	H5404_037_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	037	0	1	01	01	H5404_037_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	037	0	1	01	01	H5404_037_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	086	0	1	02	01	H5404_086_0	6	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5404	086	0	1	02	01	H5404_086_0	6	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5404	086	0	1	02	01	H5404_086_0	6	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5404	086	0	1	02	01	H5404_086_0	6	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	3.00	9.00	6.00							3.00		3.00	6.00	6.00							3.00			
H5404	086	0	1	02	01	H5404_086_0	6	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	114	0	1	01	01	H5404_114_0	6	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	114	0	1	01	01	H5404_114_0	6	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	114	0	1	01	01	H5404_114_0	6	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	114	0	1	01	01	H5404_114_0	6	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	114	0	1	01	01	H5404_114_0	6	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	135	0	1	01	01	H5404_135_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	135	0	1	01	01	H5404_135_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	135	0	1	01	01	H5404_135_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	135	0	1	01	01	H5404_135_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	135	0	1	01	01	H5404_135_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	136	0	1	01	01	H5404_136_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	136	0	1	01	01	H5404_136_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	136	0	1	01	01	H5404_136_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	136	0	1	01	01	H5404_136_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	136	0	1	01	01	H5404_136_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	137	0	1	01	01	H5404_137_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5404	137	0	1	01	01	H5404_137_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	137	0	1	01	01	H5404_137_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5404	137	0	1	01	01	H5404_137_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H5404	137	0	1	01	01	H5404_137_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	138	0	1	01	01	H5404_138_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	138	0	1	01	01	H5404_138_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00	40.00							20.00		20.00	40.00	40.00							20.00			
H5404	138	0	1	01	01	H5404_138_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	50.00	150.00	100.00							50.00		50.00	100.00	100.00							50.00			
H5404	138	0	1	01	01	H5404_138_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	138	0	1	01	01	H5404_138_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	139	0	1	01	01	H5404_139_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5404	139	0	1	01	01	H5404_139_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00	40.00							20.00		20.00	40.00	40.00							20.00			
H5404	139	0	1	01	01	H5404_139_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	50.00	150.00	100.00							50.00		50.00	100.00	100.00							50.00			
H5404	139	0	1	01	01	H5404_139_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5404	139	0	1	01	01	H5404_139_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5407	001	0	1	02	01	H5407_001_0	6	4	4	3	Specialty	100011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5407	001	0	1	02	01	H5407_001_0	6	1	4	1	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00			
H5407	001	0	1	02	01	H5407_001_0	6	2	4	1	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Brands and Non-Preferred Generics	2	Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics	39.00	117.00								39.00			117.00								39.00			
H5407	001	0	1	02	01	H5407_001_0	6	3	4	1	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brands	2	Non-Preferred Brands																						Non-Preferred Brands	69.00	207.00								69.00			207.00								69.00			
H5407	001	0	1	02	01	H5407_001_0	6	4	4	1	Specialty	100011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5407	001	0	1	02	01	H5407_001_0	6	1	4	3	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00	1	1	
H5407	001	0	1	02	01	H5407_001_0	6	2	4	3	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics																								Preferred Brands and Non-Preferred Generics		Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics																						2		
H5407	001	0	1	02	01	H5407_001_0	6	3	4	3	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands																								Non-Preferred Brands		Non-Preferred Brands																						Non-Preferred Brands																						2		
H5407	004	0	1	02	01	H5407_004_0	6	2	4	1	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Brands and Non-Preferred Generics	2	Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics	39.00	117.00								39.00			117.00								39.00			
H5407	004	0	1	02	01	H5407_004_0	6	4	4	3	Specialty	100011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5407	004	0	1	02	01	H5407_004_0	6	3	4	3	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands																								Non-Preferred Brands		Non-Preferred Brands																						Non-Preferred Brands																						2		
H5407	004	0	1	02	01	H5407_004_0	6	2	4	3	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics																								Preferred Brands and Non-Preferred Generics		Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics																						2		
H5407	004	0	1	02	01	H5407_004_0	6	1	4	3	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00	1	1	
H5407	004	0	1	02	01	H5407_004_0	6	1	4	1	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00			
H5407	004	0	1	02	01	H5407_004_0	6	3	4	1	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brands	2	Non-Preferred Brands																						Non-Preferred Brands	69.00	207.00								69.00			207.00								69.00			
H5407	004	0	1	02	01	H5407_004_0	6	4	4	1	Specialty	100011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5407	005	0	1	02	01	H5407_005_0	6	3	4	3	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands																								Non-Preferred Brands		Non-Preferred Brands																						Non-Preferred Brands																						2		
H5407	005	0	1	02	01	H5407_005_0	6	2	4	1	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Brands and Non-Preferred Generics	2	Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics	39.00	117.00								39.00			117.00								39.00			
H5407	005	0	1	02	01	H5407_005_0	6	1	4	1	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00			
H5407	005	0	1	02	01	H5407_005_0	6	4	4	3	Specialty	100011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5407	005	0	1	02	01	H5407_005_0	6	2	4	3	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics																								Preferred Brands and Non-Preferred Generics		Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics																						2		
H5407	005	0	1	02	01	H5407_005_0	6	1	4	3	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00	1	1	
H5407	005	0	1	02	01	H5407_005_0	6	4	4	1	Specialty	100011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5407	005	0	1	02	01	H5407_005_0	6	3	4	1	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brands	2	Non-Preferred Brands																						Non-Preferred Brands	69.00	207.00								69.00			207.00								69.00			
H5407	009	0	1	02	01	H5407_009_0	7	2	4	3	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics																								Preferred Brands and Non-Preferred Generics		Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics																						2		
H5407	009	0	1	02	01	H5407_009_0	7	3	4	3	Non-Preferred Brands	100000	3	2	1	Non-Preferred Brands																								Non-Preferred Brands		Non-Preferred Brands																						Non-Preferred Brands																						2		
H5407	009	0	1	02	01	H5407_009_0	7	4	4	1	Specialty	100011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5407	009	0	1	02	01	H5407_009_0	7	3	4	1	Non-Preferred Brands	100000	3	2	1	Non-Preferred Brands	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brands	2	Non-Preferred Brands																						Non-Preferred Brands	69.00	207.00								69.00			207.00								69.00			
H5407	009	0	1	02	01	H5407_009_0	7	2	4	1	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Brands and Non-Preferred Generics	2	Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics	39.00	117.00								39.00			117.00								39.00			
H5407	009	0	1	02	01	H5407_009_0	7	1	4	1	Preferred Generics	011000	3	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00			
H5407	009	0	1	02	01	H5407_009_0	7	4	4	3	Specialty	100011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5407	009	0	1	02	01	H5407_009_0	7	1	4	3	Preferred Generics	011000	3	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00	1	1	
H5407	014	0	1	02	01	H5407_014_0	6	4	4	3	Specialty	100011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5407	014	0	1	02	01	H5407_014_0	6	2	4	1	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Brands and Non-Preferred Generics	2	Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics	39.00	117.00								39.00			117.00								39.00			
H5407	014	0	1	02	01	H5407_014_0	6	1	4	3	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00	1	1	
H5407	014	0	1	02	01	H5407_014_0	6	1	4	1	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00			
H5407	014	0	1	02	01	H5407_014_0	6	2	4	3	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics																								Preferred Brands and Non-Preferred Generics		Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics																						2		
H5407	014	0	1	02	01	H5407_014_0	6	3	4	3	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands																								Non-Preferred Brands		Non-Preferred Brands																						Non-Preferred Brands																						2		
H5407	014	0	1	02	01	H5407_014_0	6	4	4	1	Specialty	100011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5407	014	0	1	02	01	H5407_014_0	6	3	4	1	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brands	2	Non-Preferred Brands																						Non-Preferred Brands	69.00	207.00								69.00			207.00								69.00			
H5407	016	0	1	02	01	H5407_016_0	8	1	4	1	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00			
H5407	016	0	1	02	01	H5407_016_0	8	2	4	1	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Brands and Non-Preferred Generics	2	Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics	39.00	117.00								39.00			117.00								39.00			
H5407	016	0	1	02	01	H5407_016_0	8	3	4	1	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brands	2	Non-Preferred Brands																						Non-Preferred Brands	69.00	207.00								69.00			207.00								69.00			
H5407	016	0	1	02	01	H5407_016_0	8	4	4	1	Specialty	100011	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5407	016	0	1	02	01	H5407_016_0	8	1	4	3	Preferred Generics	011000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	1	Preferred Generics	2	Preferred Generics																						Preferred Generics	0.00	0.00								0.00			0.00								0.00	1	1	
H5407	016	0	1	02	01	H5407_016_0	8	3	4	3	Non-Preferred Brands	100000	1	2	1	Non-Preferred Brands																								Non-Preferred Brands		Non-Preferred Brands																						Non-Preferred Brands																						2		
H5407	016	0	1	02	01	H5407_016_0	8	4	4	3	Specialty	100011	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5407	016	0	1	02	01	H5407_016_0	8	2	4	3	Preferred Brands and Non-Preferred Generics	100001	1	2	2	Preferred Brands and Non-Preferred Generics																								Preferred Brands and Non-Preferred Generics		Preferred Brands and Non-Preferred Generics																						Preferred Brands and Non-Preferred Generics																						2		
H5410	001	0	1	01	01	H5410_001_0	7	3	4	3	Specialty Drugs	010010	1	1	1	Specialty Drugs	100010010010000000000				30			30			30											31		Specialty Drugs	1	Specialty Drugs				33			33			33											33	Specialty Drugs																						1	2	01000000
H5410	001	0	1	01	01	H5410_001_0	7	2	4	3	Brand Name Drugs	000010	1	2	2	Brand Name Drugs																								Brand Name Drugs		Brand Name Drugs																						Brand Name Drugs																						2		
H5410	001	0	1	01	01	H5410_001_0	7	1	4	3	Generic Drugs	010000	3	2	2	Generic Drugs	100010010010000000000				30			30			30											31		Generic Drugs	2	Generic Drugs																						Generic Drugs				0.00			5.00			5.00											5.00	1	1	
H5410	001	0	1	01	01	H5410_001_0	7	3	4	1	Specialty Drugs	010010	1	1	1	Specialty Drugs	100010010010000000000				30			30			30											31		Specialty Drugs	1	Specialty Drugs				33			33			33											33	Specialty Drugs																								
H5410	001	0	1	01	01	H5410_001_0	7	2	4	1	Brand Name Drugs	000010	1	2	2	Brand Name Drugs	100010010010000000000				30			30			30											31		Brand Name Drugs	2	Brand Name Drugs																						Brand Name Drugs				0.00			10.00			10.00											10.00			
H5410	001	0	1	01	01	H5410_001_0	7	1	4	1	Generic Drugs	010000	3	2	2	Generic Drugs	100010010010000000000				30			30			30											31		Generic Drugs	2	Generic Drugs																						Generic Drugs				0.00			5.00			5.00											5.00			
H5410	003	0	1	01	01	H5410_003_0	4	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5410	003	0	1	01	01	H5410_003_0	4	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5410	003	0	1	01	01	H5410_003_0	4	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5410	003	0	1	01	01	H5410_003_0	4	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00	1	1	
H5410	003	0	1	01	01	H5410_003_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H5410	003	0	1	01	01	H5410_003_0	4	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H5410	003	0	1	01	01	H5410_003_0	4	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	4	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			105.00								35.00			
H5410	003	0	1	01	01	H5410_003_0	4	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			30.00								10.00			
H5410	003	0	1	01	01	H5410_003_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H5410	005	0	1	01	01	H5410_005_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H5410	005	0	1	01	01	H5410_005_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00			45.00								15.00			
H5410	005	0	1	01	01	H5410_005_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5410	005	0	1	01	01	H5410_005_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H5410	005	0	1	01	01	H5410_005_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	15.00	45.00								15.00			45.00								15.00	1	1	
H5410	005	0	1	01	01	H5410_005_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H5410	005	0	1	01	01	H5410_005_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5410	005	0	1	01	01	H5410_005_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5410	005	0	1	01	01	H5410_005_0	5	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5410	005	0	1	01	01	H5410_005_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H5414	002	0	1	01	01	H5414_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																						2		
H5414	002	0	1	01	01	H5414_002_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5414	002	0	1	01	01	H5414_002_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																						2		
H5414	002	0	1	01	01	H5414_002_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	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	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5414	002	0	1	01	01	H5414_002_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H5414	002	0	1	01	01	H5414_002_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5414	002	0	1	01	01	H5414_002_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H5414	002	0	1	01	01	H5414_002_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5414	002	0	1	01	01	H5414_002_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5414	009	0	1	01	01	H5414_009_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5414	009	0	1	01	01	H5414_009_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5414	009	0	1	01	01	H5414_009_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5414	009	0	1	01	01	H5414_009_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					74.00			111.00		37.00			
H5414	009	0	1	01	01	H5414_009_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H5414	010	0	1	01	01	H5414_010_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	31.00	93.00									31.00					62.00			93.00		31.00			
H5414	010	0	1	01	01	H5414_010_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00			
H5414	010	0	1	01	01	H5414_010_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5414	010	0	1	01	01	H5414_010_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5414	010	0	1	01	01	H5414_010_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00			
H5414	012	0	1	01	01	H5414_012_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5414	012	0	1	01	01	H5414_012_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																						2		
H5414	012	0	1	01	01	H5414_012_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5414	012	0	1	01	01	H5414_012_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5414	012	0	1	01	01	H5414_012_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5414	012	0	1	01	01	H5414_012_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H5414	012	0	1	01	01	H5414_012_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5414	012	0	1	01	01	H5414_012_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5414	012	0	1	01	01	H5414_012_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5414	012	0	1	01	01	H5414_012_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5414	019	0	1	01	01	H5414_019_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5414	019	0	1	01	01	H5414_019_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5414	019	0	1	01	01	H5414_019_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	34.00	102.00									34.00					68.00			102.00		34.00			
H5414	019	0	1	01	01	H5414_019_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5414	019	0	1	01	01	H5414_019_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5414	020	0	1	01	01	H5414_020_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5414	020	0	1	01	01	H5414_020_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H5414	020	0	1	01	01	H5414_020_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5414	020	0	1	01	01	H5414_020_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5414	020	0	1	01	01	H5414_020_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5414	020	0	1	01	01	H5414_020_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																						2		
H5414	020	0	1	01	01	H5414_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																						2		
H5414	020	0	1	01	01	H5414_020_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5414	020	0	1	01	01	H5414_020_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5414	020	0	1	01	01	H5414_020_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5415	039	0	1	04	01	H5415_039_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5415	039	0	1	04	01	H5415_039_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5415	039	0	1	04	01	H5415_039_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5415	039	0	1	04	01	H5415_039_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5415	039	0	1	04	01	H5415_039_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5415	039	0	1	04	01	H5415_039_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5416	001	0	1	01	01	H5416_001_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	001	0	1	01	01	H5416_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	001	0	1	01	01	H5416_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	001	0	1	01	01	H5416_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	001	0	1	01	01	H5416_001_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	001	0	1	01	01	H5416_001_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	001	0	1	01	01	H5416_001_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	001	0	1	01	01	H5416_001_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	001	0	1	01	01	H5416_001_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																						2		
H5416	001	0	1	01	01	H5416_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	002	0	1	01	01	H5416_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	002	0	1	01	01	H5416_002_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	002	0	1	01	01	H5416_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	002	0	1	01	01	H5416_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																						2		
H5416	002	0	1	01	01	H5416_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	002	0	1	01	01	H5416_002_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	002	0	1	01	01	H5416_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	002	0	1	01	01	H5416_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	002	0	1	01	01	H5416_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	002	0	1	01	01	H5416_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	004	0	1	01	01	H5416_004_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	004	0	1	01	01	H5416_004_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	004	0	1	01	01	H5416_004_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5416	004	0	1	01	01	H5416_004_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5416	004	0	1	01	01	H5416_004_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	004	0	1	01	01	H5416_004_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	004	0	1	01	01	H5416_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																						2		
H5416	004	0	1	01	01	H5416_004_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	004	0	1	01	01	H5416_004_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	1	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	004	0	1	01	01	H5416_004_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5416	009	0	1	01	01	H5416_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																						2		
H5416	009	0	1	01	01	H5416_009_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	009	0	1	01	01	H5416_009_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	009	0	1	01	01	H5416_009_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	009	0	1	01	01	H5416_009_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	009	0	1	01	01	H5416_009_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	009	0	1	01	01	H5416_009_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	009	0	1	01	01	H5416_009_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	009	0	1	01	01	H5416_009_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	009	0	1	01	01	H5416_009_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	011	0	1	01	01	H5416_011_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	011	0	1	01	01	H5416_011_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	011	0	1	01	01	H5416_011_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	011	0	1	01	01	H5416_011_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	011	0	1	01	01	H5416_011_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H5416	011	0	1	01	01	H5416_011_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	011	0	1	01	01	H5416_011_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	011	0	1	01	01	H5416_011_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																						2		
H5416	011	0	1	01	01	H5416_011_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	011	0	1	01	01	H5416_011_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	013	0	1	01	01	H5416_013_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H5416	013	0	1	01	01	H5416_013_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	013	0	1	01	01	H5416_013_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																						2		
H5416	013	0	1	01	01	H5416_013_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	013	0	1	01	01	H5416_013_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5416	013	0	1	01	01	H5416_013_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	013	0	1	01	01	H5416_013_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	013	0	1	01	01	H5416_013_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	013	0	1	01	01	H5416_013_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5416	013	0	1	01	01	H5416_013_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	016	0	1	01	01	H5416_016_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	016	0	1	01	01	H5416_016_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	016	0	1	01	01	H5416_016_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	016	0	1	01	01	H5416_016_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	016	0	1	01	01	H5416_016_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	016	0	1	01	01	H5416_016_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5416	016	0	1	01	01	H5416_016_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	016	0	1	01	01	H5416_016_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																						2		
H5416	016	0	1	01	01	H5416_016_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	016	0	1	01	01	H5416_016_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	017	0	1	01	01	H5416_017_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	017	0	1	01	01	H5416_017_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	017	0	1	01	01	H5416_017_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	017	0	1	01	01	H5416_017_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	017	0	1	01	01	H5416_017_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	017	0	1	01	01	H5416_017_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	017	0	1	01	01	H5416_017_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	017	0	1	01	01	H5416_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																						2		
H5416	017	0	1	01	01	H5416_017_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	017	0	1	01	01	H5416_017_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	018	0	1	01	01	H5416_018_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	018	0	1	01	01	H5416_018_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																						2		
H5416	018	0	1	01	01	H5416_018_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	018	0	1	01	01	H5416_018_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	018	0	1	01	01	H5416_018_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	018	0	1	01	01	H5416_018_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	018	0	1	01	01	H5416_018_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	018	0	1	01	01	H5416_018_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	018	0	1	01	01	H5416_018_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	018	0	1	01	01	H5416_018_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	020	0	1	01	01	H5416_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																						2		
H5416	020	0	1	01	01	H5416_020_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	020	0	1	01	01	H5416_020_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	020	0	1	01	01	H5416_020_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5416	020	0	1	01	01	H5416_020_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	020	0	1	01	01	H5416_020_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	020	0	1	01	01	H5416_020_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	020	0	1	01	01	H5416_020_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	020	0	1	01	01	H5416_020_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5416	020	0	1	01	01	H5416_020_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	021	0	1	01	01	H5416_021_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5416	021	0	1	01	01	H5416_021_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	021	0	1	01	01	H5416_021_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	021	0	1	01	01	H5416_021_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	021	0	1	01	01	H5416_021_0	8	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	021	0	1	01	01	H5416_021_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5416	021	0	1	01	01	H5416_021_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	021	0	1	01	01	H5416_021_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																						2		
H5416	021	0	1	01	01	H5416_021_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	021	0	1	01	01	H5416_021_0	8	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	023	0	1	01	01	H5416_023_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5416	023	0	1	01	01	H5416_023_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5416	023	0	1	01	01	H5416_023_0	8	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	023	0	1	01	01	H5416_023_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	023	0	1	01	01	H5416_023_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	023	0	1	01	01	H5416_023_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5416	023	0	1	01	01	H5416_023_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5416	023	0	1	01	01	H5416_023_0	8	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	023	0	1	01	01	H5416_023_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	023	0	1	01	01	H5416_023_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																						2		
H5416	029	0	1	02	01	H5416_029_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	029	0	1	02	01	H5416_029_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H5416	029	0	1	02	01	H5416_029_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H5416	029	0	1	02	01	H5416_029_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5416	029	0	1	02	01	H5416_029_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	029	0	1	02	01	H5416_029_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5416	029	0	1	02	01	H5416_029_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	029	0	1	02	01	H5416_029_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5416	029	0	1	02	01	H5416_029_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H5416	029	0	1	02	01	H5416_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																						2		
H5416	030	0	1	02	01	H5416_030_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5416	030	0	1	02	01	H5416_030_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5416	030	0	1	02	01	H5416_030_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																						2		
H5416	030	0	1	02	01	H5416_030_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5416	030	0	1	02	01	H5416_030_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5416	030	0	1	02	01	H5416_030_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5416	030	0	1	02	01	H5416_030_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5416	030	0	1	02	01	H5416_030_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5416	030	0	1	02	01	H5416_030_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5416	030	0	1	02	01	H5416_030_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H5417	005	0	1	04	01	H5417_005_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H5417	005	0	1	04	01	H5417_005_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5417	005	0	1	04	01	H5417_005_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H5417	005	0	1	04	01	H5417_005_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5419	004	0	1	09	04	H5419_004_0	14	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5419	004	0	1	09	04	H5419_004_0	14	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5419	004	0	1	09	04	H5419_004_0	14	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H5419	004	0	1	09	04	H5419_004_0	14	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5419	004	0	1	09	04	H5419_004_0	14	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5419	004	0	1	09	04	H5419_004_0	14	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H5419	004	0	1	09	04	H5419_004_0	14	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5419	004	0	1	09	04	H5419_004_0	14	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5419	004	0	1	09	04	H5419_004_0	14	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5419	004	0	1	09	04	H5419_004_0	14	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H5420	001	0	1	05	01	H5420_001_0	6	4	4	1	Non-Preferred Brand	000010	1	2	1	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	10.00									10.00											10.00			
H5420	001	0	1	05	01	H5420_001_0	6	3	4	1	Formulary Brand	000010	3	2	2	Formulary Brand	110000000010000000000	30									30											31		Formulary Brand	2	Formulary Brand																						Formulary Brand	5.00									5.00											5.00			
H5420	001	0	1	05	01	H5420_001_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00									0.00											0.00			
H5420	001	0	1	05	01	H5420_001_0	6	1	4	1	Generic	010000	3	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	0.00									0.00											0.00			
H5420	001	0	1	05	01	H5420_001_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5420	003	0	1	05	01	H5420_003_0	4	1	4	3	Generic	010000	3	2	2	Generic	100010010010000000000				30			30			30											31		Generic	2	Generic																						Generic				0.00			0.00			0.00											0.00	1	1	
H5420	003	0	1	05	01	H5420_003_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5420	003	0	1	05	01	H5420_003_0	4	3	4	3	Formulary Brand	000010	3	2	2	Formulary Brand																								Formulary Brand		Formulary Brand																						Formulary Brand																						2		
H5420	003	0	1	05	01	H5420_003_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				33			33			33											33	Specialty																								
H5420	003	0	1	05	01	H5420_003_0	4	4	4	1	Non-Preferred Brand	000010	1	2	1	Non-Preferred Brand	100010010010000000000				30			30			30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00			
H5420	003	0	1	05	01	H5420_003_0	4	3	4	1	Formulary Brand	000010	3	2	2	Formulary Brand	100010010010000000000				30			30			30											31		Formulary Brand	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00			
H5420	003	0	1	05	01	H5420_003_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100010010010000000000				30			30			30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00			
H5420	003	0	1	05	01	H5420_003_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5420	003	0	1	05	01	H5420_003_0	4	1	4	1	Generic	010000	3	2	2	Generic	100010010010000000000				30			30			30											31		Generic	2	Generic																						Generic				0.00			0.00			0.00											0.00			
H5420	003	0	1	05	01	H5420_003_0	4	4	4	3	Non-Preferred Brand	000010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5420	004	0	1	05	01	H5420_004_0	4	1	4	1	Generic	010000	3	2	2	Generic	100010010010000000000				30			30			30											31		Generic	2	Generic																						Generic				0.00			0.00			0.00											0.00			
H5420	004	0	1	05	01	H5420_004_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100010010010000000000				30			30			30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00			
H5420	004	0	1	05	01	H5420_004_0	4	3	4	1	Formulary Brand	000010	3	2	2	Formulary Brand	100010010010000000000				30			30			30											31		Formulary Brand	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00			
H5420	004	0	1	05	01	H5420_004_0	4	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	100010010010000000000				30			30			30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00			
H5420	004	0	1	05	01	H5420_004_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5420	004	0	1	05	01	H5420_004_0	4	1	4	3	Generic	010000	3	2	2	Generic	100010010010000000000				30			30			30											31		Generic	2	Generic																						Generic				0.00			0.00			0.00											0.00	1	1	
H5420	004	0	1	05	01	H5420_004_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	100010010010000000000				30			30			30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00	1	1	
H5420	004	0	1	05	01	H5420_004_0	4	3	4	3	Formulary Brand	000010	3	2	2	Formulary Brand																								Formulary Brand		Formulary Brand																						Formulary Brand																						2		
H5420	004	0	1	05	01	H5420_004_0	4	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5420	004	0	1	05	01	H5420_004_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				33			33			33											33	Specialty																								
H5420	005	0	1	05	01	H5420_005_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				33			33			33											33	Specialty																								
H5420	005	0	1	05	01	H5420_005_0	6	1	4	3	Generic	010000	3	2	2	Generic	100010010010000000000				30			30			30											31		Generic	2	Generic																						Generic				0.00			0.00			0.00											0.00	1	1	
H5420	005	0	1	05	01	H5420_005_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5420	005	0	1	05	01	H5420_005_0	6	3	4	3	Formulary Brand	000010	3	2	2	Formulary Brand																								Formulary Brand		Formulary Brand																						Formulary Brand																						2		
H5420	005	0	1	05	01	H5420_005_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5420	005	0	1	05	01	H5420_005_0	6	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5420	005	0	1	05	01	H5420_005_0	6	1	4	1	Generic	010000	3	2	2	Generic	100010010010000000000				30			30			30											31		Generic	2	Generic																						Generic				0.00			0.00			0.00											0.00			
H5420	005	0	1	05	01	H5420_005_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100010010010000000000				30			30			30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand				0.00			0.00			0.00											0.00			
H5420	005	0	1	05	01	H5420_005_0	6	3	4	1	Formulary Brand	000010	3	2	2	Formulary Brand	100010010010000000000				30			30			30											31		Formulary Brand	2	Formulary Brand																						Formulary Brand				5.00			10.00			10.00											10.00			
H5420	005	0	1	05	01	H5420_005_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	100010010010000000000				30			30			30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				20.00			25.00			25.00											25.00			
H5420	006	0	1	05	01	H5420_006_0	6	1	4	1	Generic	010000	3	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	0.00									0.00											0.00			
H5420	006	0	1	05	01	H5420_006_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00									0.00											0.00			
H5420	006	0	1	05	01	H5420_006_0	6	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5420	006	0	1	05	01	H5420_006_0	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5420	006	0	1	05	01	H5420_006_0	6	3	4	3	Formulary Brand	000010	3	2	2	Formulary Brand																								Formulary Brand		Formulary Brand																						Formulary Brand																						2		
H5420	006	0	1	05	01	H5420_006_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00									0.00											0.00	1	1	
H5420	006	0	1	05	01	H5420_006_0	6	3	4	1	Formulary Brand	000010	3	2	2	Formulary Brand	110000000010000000000	30									30											31		Formulary Brand	1	Formulary Brand	35									35											35	Formulary Brand																								
H5420	006	0	1	05	01	H5420_006_0	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	35									35											35	Non-Preferred Brand																								
H5420	006	0	1	05	01	H5420_006_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5420	006	0	1	05	01	H5420_006_0	6	1	4	3	Generic	010000	3	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	0.00									0.00											0.00	1	1	
H5420	009	0	1	05	01	H5420_009_0	9	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	25.00									25.00											25.00			
H5420	009	0	1	05	01	H5420_009_0	9	3	4	1	Formulary Brand	000010	3	2	2	Formulary Brand	110000000010000000000	30									30											31		Formulary Brand	2	Formulary Brand																						Formulary Brand	10.00									10.00											10.00			
H5420	009	0	1	05	01	H5420_009_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00									0.00											0.00			
H5420	009	0	1	05	01	H5420_009_0	9	1	4	1	Generic	010000	3	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	0.00									0.00											0.00			
H5420	009	0	1	05	01	H5420_009_0	9	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	064	0	1	09	04	H5421_064_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	064	0	1	09	04	H5421_064_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	064	0	1	09	04	H5421_064_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	064	0	1	09	04	H5421_064_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	064	0	1	09	04	H5421_064_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	064	0	1	09	04	H5421_064_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	064	0	1	09	04	H5421_064_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	064	0	1	09	04	H5421_064_0	7	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	065	0	1	09	04	H5421_065_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	065	0	1	09	04	H5421_065_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	065	0	1	09	04	H5421_065_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	065	0	1	09	04	H5421_065_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	065	0	1	09	04	H5421_065_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	065	0	1	09	04	H5421_065_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	065	0	1	09	04	H5421_065_0	7	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	065	0	1	09	04	H5421_065_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	066	0	1	09	04	H5421_066_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	066	0	1	09	04	H5421_066_0	7	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	066	0	1	09	04	H5421_066_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	066	0	1	09	04	H5421_066_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	066	0	1	09	04	H5421_066_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	066	0	1	09	04	H5421_066_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	066	0	1	09	04	H5421_066_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	066	0	1	09	04	H5421_066_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	067	0	1	09	04	H5421_067_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	067	0	1	09	04	H5421_067_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	067	0	1	09	04	H5421_067_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	067	0	1	09	04	H5421_067_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	067	0	1	09	04	H5421_067_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	067	0	1	09	04	H5421_067_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	067	0	1	09	04	H5421_067_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	067	0	1	09	04	H5421_067_0	7	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	068	0	1	09	04	H5421_068_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	068	0	1	09	04	H5421_068_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	068	0	1	09	04	H5421_068_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	068	0	1	09	04	H5421_068_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	068	0	1	09	04	H5421_068_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	068	0	1	09	04	H5421_068_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	068	0	1	09	04	H5421_068_0	7	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	068	0	1	09	04	H5421_068_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	069	0	1	09	04	H5421_069_0	7	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	069	0	1	09	04	H5421_069_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	069	0	1	09	04	H5421_069_0	7	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	069	0	1	09	04	H5421_069_0	7	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	069	0	1	09	04	H5421_069_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	069	0	1	09	04	H5421_069_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	069	0	1	09	04	H5421_069_0	7	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	069	0	1	09	04	H5421_069_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	070	0	1	09	04	H5421_070_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	070	0	1	09	04	H5421_070_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	070	0	1	09	04	H5421_070_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	070	0	1	09	04	H5421_070_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	071	0	1	09	04	H5421_071_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	071	0	1	09	04	H5421_071_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	071	0	1	09	04	H5421_071_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	071	0	1	09	04	H5421_071_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	072	0	1	09	04	H5421_072_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	072	0	1	09	04	H5421_072_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	072	0	1	09	04	H5421_072_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	072	0	1	09	04	H5421_072_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	073	0	1	09	04	H5421_073_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	073	0	1	09	04	H5421_073_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	073	0	1	09	04	H5421_073_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	073	0	1	09	04	H5421_073_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	074	0	1	09	04	H5421_074_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	074	0	1	09	04	H5421_074_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	074	0	1	09	04	H5421_074_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	074	0	1	09	04	H5421_074_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	075	0	1	09	04	H5421_075_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	075	0	1	09	04	H5421_075_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	075	0	1	09	04	H5421_075_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	075	0	1	09	04	H5421_075_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	103	0	1	09	04	H5421_103_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	103	0	1	09	04	H5421_103_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	103	0	1	09	04	H5421_103_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	103	0	1	09	04	H5421_103_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	103	0	1	09	04	H5421_103_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	103	0	1	09	04	H5421_103_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	103	0	1	09	04	H5421_103_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	103	0	1	09	04	H5421_103_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	104	0	1	09	04	H5421_104_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	104	0	1	09	04	H5421_104_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	104	0	1	09	04	H5421_104_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	104	0	1	09	04	H5421_104_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	109	0	1	09	04	H5421_109_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
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																						2		
H5421	109	0	1	09	04	H5421_109_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	109	0	1	09	04	H5421_109_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	109	0	1	09	04	H5421_109_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	109	0	1	09	04	H5421_109_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	109	0	1	09	04	H5421_109_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	109	0	1	09	04	H5421_109_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	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	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	110	0	1	09	04	H5421_110_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	110	0	1	09	04	H5421_110_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	110	0	1	09	04	H5421_110_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	115	0	1	09	04	H5421_115_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	115	0	1	09	04	H5421_115_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	115	0	1	09	04	H5421_115_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	115	0	1	09	04	H5421_115_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	115	0	1	09	04	H5421_115_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	115	0	1	09	04	H5421_115_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	115	0	1	09	04	H5421_115_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	115	0	1	09	04	H5421_115_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	116	0	1	09	04	H5421_116_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	116	0	1	09	04	H5421_116_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	116	0	1	09	04	H5421_116_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	116	0	1	09	04	H5421_116_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	127	0	1	09	04	H5421_127_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	127	0	1	09	04	H5421_127_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	127	0	1	09	04	H5421_127_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	127	0	1	09	04	H5421_127_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	127	0	1	09	04	H5421_127_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	127	0	1	09	04	H5421_127_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	127	0	1	09	04	H5421_127_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	127	0	1	09	04	H5421_127_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	128	0	1	09	04	H5421_128_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	128	0	1	09	04	H5421_128_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	128	0	1	09	04	H5421_128_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	128	0	1	09	04	H5421_128_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	133	0	1	09	04	H5421_133_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	133	0	1	09	04	H5421_133_0	9	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	133	0	1	09	04	H5421_133_0	9	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	133	0	1	09	04	H5421_133_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	133	0	1	09	04	H5421_133_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	133	0	1	09	04	H5421_133_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	133	0	1	09	04	H5421_133_0	9	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	133	0	1	09	04	H5421_133_0	9	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	134	0	1	09	04	H5421_134_0	8	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	134	0	1	09	04	H5421_134_0	8	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	134	0	1	09	04	H5421_134_0	8	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	134	0	1	09	04	H5421_134_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	140	0	1	09	04	H5421_140_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	140	0	1	09	04	H5421_140_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	140	0	1	09	04	H5421_140_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	140	0	1	09	04	H5421_140_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	140	0	1	09	04	H5421_140_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	140	0	1	09	04	H5421_140_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	140	0	1	09	04	H5421_140_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	140	0	1	09	04	H5421_140_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	142	0	1	09	04	H5421_142_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	142	0	1	09	04	H5421_142_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	142	0	1	09	04	H5421_142_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	142	0	1	09	04	H5421_142_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	148	0	1	09	04	H5421_148_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	148	0	1	09	04	H5421_148_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	148	0	1	09	04	H5421_148_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	148	0	1	09	04	H5421_148_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	148	0	1	09	04	H5421_148_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	148	0	1	09	04	H5421_148_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	148	0	1	09	04	H5421_148_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	148	0	1	09	04	H5421_148_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	150	0	1	09	04	H5421_150_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	150	0	1	09	04	H5421_150_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	150	0	1	09	04	H5421_150_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	150	0	1	09	04	H5421_150_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	156	0	1	09	04	H5421_156_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	156	0	1	09	04	H5421_156_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	156	0	1	09	04	H5421_156_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	156	0	1	09	04	H5421_156_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	156	0	1	09	04	H5421_156_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	156	0	1	09	04	H5421_156_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	156	0	1	09	04	H5421_156_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	156	0	1	09	04	H5421_156_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	158	0	1	09	04	H5421_158_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	158	0	1	09	04	H5421_158_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	158	0	1	09	04	H5421_158_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	158	0	1	09	04	H5421_158_0	5	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	164	0	1	09	04	H5421_164_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	164	0	1	09	04	H5421_164_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	164	0	1	09	04	H5421_164_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	164	0	1	09	04	H5421_164_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	164	0	1	09	04	H5421_164_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	164	0	1	09	04	H5421_164_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	164	0	1	09	04	H5421_164_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	164	0	1	09	04	H5421_164_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	172	0	1	09	04	H5421_172_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	172	0	1	09	04	H5421_172_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5421	172	0	1	09	04	H5421_172_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	172	0	1	09	04	H5421_172_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	172	0	1	09	04	H5421_172_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	172	0	1	09	04	H5421_172_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	172	0	1	09	04	H5421_172_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	172	0	1	09	04	H5421_172_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	180	0	1	09	04	H5421_180_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
H5421	180	0	1	09	04	H5421_180_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
H5421	180	0	1	09	04	H5421_180_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
H5421	180	0	1	09	04	H5421_180_0	6	4	4	1	Specialty	100001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5421	180	0	1	09	04	H5421_180_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00	1	1	
H5421	180	0	1	09	04	H5421_180_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5421	180	0	1	09	04	H5421_180_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5421	180	0	1	09	04	H5421_180_0	6	4	4	3	Specialty	100001	1	1	2																																																																							2		
H5422	002	0	1	01	01	H5422_002_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5422	002	0	1	01	01	H5422_002_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5422	002	0	1	01	01	H5422_002_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5422	002	0	1	01	01	H5422_002_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5422	002	0	1	01	01	H5422_002_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5422	002	0	1	01	01	H5422_002_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5422	002	0	1	01	01	H5422_002_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5422	002	0	1	01	01	H5422_002_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5422	002	0	1	01	01	H5422_002_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5422	002	0	1	01	01	H5422_002_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5422	006	0	1	01	01	H5422_006_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5422	006	0	1	01	01	H5422_006_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5422	006	0	1	01	01	H5422_006_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5422	006	0	1	01	01	H5422_006_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5422	006	0	1	01	01	H5422_006_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5422	006	0	1	01	01	H5422_006_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5422	006	0	1	01	01	H5422_006_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5422	006	0	1	01	01	H5422_006_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5422	006	0	1	01	01	H5422_006_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5422	006	0	1	01	01	H5422_006_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5424	001	0	1	04	01	H5424_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5424	001	0	1	04	01	H5424_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5424	001	0	1	04	01	H5424_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H5424	001	0	1	04	01	H5424_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5425	001	0	1	01	01	H5425_001_0	6	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	001	0	1	01	01	H5425_001_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	001	0	1	01	01	H5425_001_0	6	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H5425	001	0	1	01	01	H5425_001_0	6	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	001	0	1	01	01	H5425_001_0	6	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	001	0	1	01	01	H5425_001_0	6	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	001	0	1	01	01	H5425_001_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	001	0	1	01	01	H5425_001_0	6	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	001	0	1	01	01	H5425_001_0	6	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	001	0	1	01	01	H5425_001_0	6	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	003	0	1	01	01	H5425_003_0	6	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	003	0	1	01	01	H5425_003_0	6	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	003	0	1	01	01	H5425_003_0	6	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	003	0	1	01	01	H5425_003_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	003	0	1	01	01	H5425_003_0	6	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	003	0	1	01	01	H5425_003_0	6	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	003	0	1	01	01	H5425_003_0	6	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	003	0	1	01	01	H5425_003_0	6	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H5425	003	0	1	01	01	H5425_003_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	003	0	1	01	01	H5425_003_0	6	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	004	0	1	01	01	H5425_004_0	5	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	004	0	1	01	01	H5425_004_0	5	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	004	0	1	01	01	H5425_004_0	5	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	004	0	1	01	01	H5425_004_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5425	004	0	1	01	01	H5425_004_0	5	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	004	0	1	01	01	H5425_004_0	5	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	004	0	1	01	01	H5425_004_0	5	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			125.00								50.00			
H5425	004	0	1	01	01	H5425_004_0	5	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	28.00	84.00								28.00			70.00								28.00			
H5425	004	0	1	01	01	H5425_004_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H5425	004	0	1	01	01	H5425_004_0	5	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	005	0	1	01	01	H5425_005_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	7.00	21.00								7.00			17.50								7.00			
H5425	005	0	1	01	01	H5425_005_0	5	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	005	0	1	01	01	H5425_005_0	5	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	28.00	84.00								28.00			70.00								28.00			
H5425	005	0	1	01	01	H5425_005_0	5	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			125.00								50.00			
H5425	005	0	1	01	01	H5425_005_0	5	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	005	0	1	01	01	H5425_005_0	5	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	005	0	1	01	01	H5425_005_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	7.00	21.00								7.00			17.50								7.00	1	1	
H5425	005	0	1	01	01	H5425_005_0	5	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	005	0	1	01	01	H5425_005_0	5	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	005	0	1	01	01	H5425_005_0	5	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	006	0	1	01	01	H5425_006_0	6	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	006	0	1	01	01	H5425_006_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H5425	006	0	1	01	01	H5425_006_0	6	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H5425	006	0	1	01	01	H5425_006_0	6	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	006	0	1	01	01	H5425_006_0	6	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	006	0	1	01	01	H5425_006_0	6	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	006	0	1	01	01	H5425_006_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5425	006	0	1	01	01	H5425_006_0	6	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	006	0	1	01	01	H5425_006_0	6	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	006	0	1	01	01	H5425_006_0	6	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	007	0	1	01	01	H5425_007_0	6	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	007	0	1	01	01	H5425_007_0	6	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	007	0	1	01	01	H5425_007_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5425	007	0	1	01	01	H5425_007_0	6	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	007	0	1	01	01	H5425_007_0	6	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	007	0	1	01	01	H5425_007_0	6	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	007	0	1	01	01	H5425_007_0	6	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	007	0	1	01	01	H5425_007_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H5425	007	0	1	01	01	H5425_007_0	6	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H5425	007	0	1	01	01	H5425_007_0	6	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	008	0	1	01	01	H5425_008_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	008	0	1	01	01	H5425_008_0	5	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	008	0	1	01	01	H5425_008_0	5	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	008	0	1	01	01	H5425_008_0	5	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	008	0	1	01	01	H5425_008_0	5	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H5425	008	0	1	01	01	H5425_008_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	008	0	1	01	01	H5425_008_0	5	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	008	0	1	01	01	H5425_008_0	5	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	008	0	1	01	01	H5425_008_0	5	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	008	0	1	01	01	H5425_008_0	5	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	009	0	1	01	01	H5425_009_0	5	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	009	0	1	01	01	H5425_009_0	5	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	009	0	1	01	01	H5425_009_0	5	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	009	0	1	01	01	H5425_009_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	009	0	1	01	01	H5425_009_0	5	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	009	0	1	01	01	H5425_009_0	5	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	009	0	1	01	01	H5425_009_0	5	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	009	0	1	01	01	H5425_009_0	5	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H5425	009	0	1	01	01	H5425_009_0	5	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	009	0	1	01	01	H5425_009_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	010	0	1	01	01	H5425_010_0	12	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	92.00	276.00								92.00			230.00								92.00			
H5425	010	0	1	01	01	H5425_010_0	12	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	34.00	102.00								34.00			85.00								34.00			
H5425	010	0	1	01	01	H5425_010_0	12	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5425	010	0	1	01	01	H5425_010_0	12	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	010	0	1	01	01	H5425_010_0	12	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	011	0	1	01	01	H5425_011_0	12	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	93.00	279.00								93.00			232.50								93.00			
H5425	011	0	1	01	01	H5425_011_0	12	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	011	0	1	01	01	H5425_011_0	12	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5425	011	0	1	01	01	H5425_011_0	12	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	011	0	1	01	01	H5425_011_0	12	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	34.00	102.00								34.00			85.00								34.00			
H5425	012	0	1	01	01	H5425_012_0	12	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	95.00	285.00								95.00			237.50								95.00			
H5425	012	0	1	01	01	H5425_012_0	12	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H5425	012	0	1	01	01	H5425_012_0	12	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5425	012	0	1	01	01	H5425_012_0	12	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	012	0	1	01	01	H5425_012_0	12	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5425	013	0	1	01	01	H5425_013_0	8	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	013	0	1	01	01	H5425_013_0	8	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	013	0	1	01	01	H5425_013_0	8	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	013	0	1	01	01	H5425_013_0	8	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	013	0	1	01	01	H5425_013_0	8	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	013	0	1	01	01	H5425_013_0	8	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	013	0	1	01	01	H5425_013_0	8	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			175.00								70.00			
H5425	013	0	1	01	01	H5425_013_0	8	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			100.00								40.00			
H5425	013	0	1	01	01	H5425_013_0	8	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	013	0	1	01	01	H5425_013_0	8	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	014	0	1	01	01	H5425_014_0	8	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	014	0	1	01	01	H5425_014_0	8	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	014	0	1	01	01	H5425_014_0	8	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	014	0	1	01	01	H5425_014_0	8	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			100.00								40.00			
H5425	014	0	1	01	01	H5425_014_0	8	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			175.00								70.00			
H5425	014	0	1	01	01	H5425_014_0	8	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	014	0	1	01	01	H5425_014_0	8	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	014	0	1	01	01	H5425_014_0	8	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	014	0	1	01	01	H5425_014_0	8	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	014	0	1	01	01	H5425_014_0	8	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	015	0	1	01	01	H5425_015_0	8	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	015	0	1	01	01	H5425_015_0	8	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	015	0	1	01	01	H5425_015_0	8	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	015	0	1	01	01	H5425_015_0	8	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			100.00								40.00			
H5425	015	0	1	01	01	H5425_015_0	8	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	015	0	1	01	01	H5425_015_0	8	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	015	0	1	01	01	H5425_015_0	8	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	015	0	1	01	01	H5425_015_0	8	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	015	0	1	01	01	H5425_015_0	8	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	015	0	1	01	01	H5425_015_0	8	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			175.00								70.00			
H5425	016	0	1	01	01	H5425_016_0	8	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H5425	016	0	1	01	01	H5425_016_0	8	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	016	0	1	01	01	H5425_016_0	8	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	016	0	1	01	01	H5425_016_0	8	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	016	0	1	01	01	H5425_016_0	8	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	016	0	1	01	01	H5425_016_0	8	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H5425	016	0	1	01	01	H5425_016_0	8	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			100.00								40.00			
H5425	016	0	1	01	01	H5425_016_0	8	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			175.00								70.00			
H5425	016	0	1	01	01	H5425_016_0	8	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	016	0	1	01	01	H5425_016_0	8	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	018	0	1	01	01	H5425_018_0	8	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	018	0	1	01	01	H5425_018_0	8	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5425	018	0	1	01	01	H5425_018_0	8	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	018	0	1	01	01	H5425_018_0	8	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	018	0	1	01	01	H5425_018_0	8	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	018	0	1	01	01	H5425_018_0	8	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H5425	018	0	1	01	01	H5425_018_0	8	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	018	0	1	01	01	H5425_018_0	8	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	018	0	1	01	01	H5425_018_0	8	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00			
H5425	018	0	1	01	01	H5425_018_0	8	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00			
H5425	019	0	1	01	01	H5425_019_0	9	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	019	0	1	01	01	H5425_019_0	9	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	019	0	1	01	01	H5425_019_0	9	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	019	0	1	01	01	H5425_019_0	9	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H5425	019	0	1	01	01	H5425_019_0	9	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	019	0	1	01	01	H5425_019_0	9	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	019	0	1	01	01	H5425_019_0	9	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00			
H5425	019	0	1	01	01	H5425_019_0	9	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00			
H5425	019	0	1	01	01	H5425_019_0	9	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5425	019	0	1	01	01	H5425_019_0	9	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	020	0	1	01	01	H5425_020_0	9	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	50.00	150.00								50.00			100.00								50.00			
H5425	020	0	1	01	01	H5425_020_0	9	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	020	0	1	01	01	H5425_020_0	9	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	020	0	1	01	01	H5425_020_0	9	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H5425	020	0	1	01	01	H5425_020_0	9	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	020	0	1	01	01	H5425_020_0	9	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	020	0	1	01	01	H5425_020_0	9	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	020	0	1	01	01	H5425_020_0	9	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	020	0	1	01	01	H5425_020_0	9	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5425	020	0	1	01	01	H5425_020_0	9	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00			
H5425	022	0	1	01	01	H5425_022_0	9	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5425	022	0	1	01	01	H5425_022_0	9	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			80.00								40.00			
H5425	022	0	1	01	01	H5425_022_0	9	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	022	0	1	01	01	H5425_022_0	9	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			140.00								70.00			
H5425	022	0	1	01	01	H5425_022_0	9	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	023	0	1	01	01	H5425_023_0	9	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	023	0	1	01	01	H5425_023_0	9	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			140.00								70.00			
H5425	023	0	1	01	01	H5425_023_0	9	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			80.00								40.00			
H5425	023	0	1	01	01	H5425_023_0	9	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5425	023	0	1	01	01	H5425_023_0	9	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	024	0	1	01	01	H5425_024_0	9	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	024	0	1	01	01	H5425_024_0	9	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	40.00	120.00								40.00			80.00								40.00			
H5425	024	0	1	01	01	H5425_024_0	9	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H5425	024	0	1	01	01	H5425_024_0	9	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	024	0	1	01	01	H5425_024_0	9	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	70.00	210.00								70.00			140.00								70.00			
H5425	025	0	1	02	01	H5425_025_0	10	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	025	0	1	02	01	H5425_025_0	10	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	025	0	1	02	01	H5425_025_0	10	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	025	0	1	02	01	H5425_025_0	10	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5425	025	0	1	02	01	H5425_025_0	10	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	025	0	1	02	01	H5425_025_0	10	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	025	0	1	02	01	H5425_025_0	10	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	025	0	1	02	01	H5425_025_0	10	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H5425	025	0	1	02	01	H5425_025_0	10	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H5425	025	0	1	02	01	H5425_025_0	10	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	026	0	1	02	01	H5425_026_0	10	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	026	0	1	02	01	H5425_026_0	10	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	026	0	1	02	01	H5425_026_0	10	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	026	0	1	02	01	H5425_026_0	10	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5425	026	0	1	02	01	H5425_026_0	10	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	026	0	1	02	01	H5425_026_0	10	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5425	026	0	1	02	01	H5425_026_0	10	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	026	0	1	02	01	H5425_026_0	10	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H5425	026	0	1	02	01	H5425_026_0	10	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H5425	026	0	1	02	01	H5425_026_0	10	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	027	0	1	02	01	H5425_027_0	10	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5425	027	0	1	02	01	H5425_027_0	10	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H5425	027	0	1	02	01	H5425_027_0	10	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H5425	027	0	1	02	01	H5425_027_0	10	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H5425	027	0	1	02	01	H5425_027_0	10	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5425	027	0	1	02	01	H5425_027_0	10	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5425	027	0	1	02	01	H5425_027_0	10	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5425	027	0	1	02	01	H5425_027_0	10	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H5425	027	0	1	02	01	H5425_027_0	10	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H5425	027	0	1	02	01	H5425_027_0	10	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5426	001	0	1	02	01	H5426_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5426	001	0	1	02	01	H5426_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00	1	2	10001000
H5426	001	0	1	02	01	H5426_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferrred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferrred Generic	2	Preferrred Generic																						Preferrred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00	1	2	00001000
H5426	001	0	1	02	01	H5426_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5426	001	0	1	02	01	H5426_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5426	001	0	1	02	01	H5426_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	45.00	135.00								45.00					45.00	112.50		45.00	135.00		45.00			
H5426	001	0	1	02	01	H5426_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00					0.00	0.00		4.00	12.00		4.00			
H5426	001	0	1	02	01	H5426_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5426	002	0	1	02	01	H5426_002_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5426	002	0	1	02	01	H5426_002_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5426	002	0	1	02	01	H5426_002_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferrred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferrred Generic	2	Preferrred Generic																						Preferrred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5426	002	0	1	02	01	H5426_002_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5426	002	0	1	02	01	H5426_002_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5426	002	0	1	02	01	H5426_002_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5426	002	0	1	02	01	H5426_002_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5426	002	0	1	02	01	H5426_002_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5426	008	0	1	02	01	H5426_008_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5426	008	0	1	02	01	H5426_008_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferrred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferrred Generic	2	Preferrred Generic																						Preferrred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5426	008	0	1	02	01	H5426_008_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5426	008	0	1	02	01	H5426_008_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5426	008	0	1	02	01	H5426_008_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5426	008	0	1	02	01	H5426_008_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5426	008	0	1	02	01	H5426_008_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5426	008	0	1	02	01	H5426_008_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5426	013	0	1	01	01	H5426_013_0	6	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00					0.00	0.00		0.00	0.00		0.00			
H5426	013	0	1	01	01	H5426_013_0	6	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	37.00	111.00								37.00					37.00	92.50		37.00	111.00		37.00			
H5426	013	0	1	01	01	H5426_013_0	6	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5426	013	0	1	01	01	H5426_013_0	6	4	3	1	Specialty	110110		1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	25									25					25			25			25	Specialty																								
H5426	019	0	1	01	01	H5426_019_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5426	019	0	1	01	01	H5426_019_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5426	019	0	1	01	01	H5426_019_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H5426	019	0	1	01	01	H5426_019_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5426	019	0	1	01	01	H5426_019_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5426	019	0	1	01	01	H5426_019_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferrred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferrred Generic	2	Preferrred Generic																						Preferrred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H5426	019	0	1	01	01	H5426_019_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5426	019	0	1	01	01	H5426_019_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5427	053	0	1	01	01	H5427_053_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	053	0	1	01	01	H5427_053_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	053	0	1	01	01	H5427_053_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	053	0	1	01	01	H5427_053_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	054	0	1	01	01	H5427_054_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	054	0	1	01	01	H5427_054_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	054	0	1	01	01	H5427_054_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	054	0	1	01	01	H5427_054_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	059	0	1	01	01	H5427_059_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	059	0	1	01	01	H5427_059_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	059	0	1	01	01	H5427_059_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	059	0	1	01	01	H5427_059_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	060	0	1	01	01	H5427_060_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	060	0	1	01	01	H5427_060_0	5	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5427	060	0	1	01	01	H5427_060_0	5	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5427	060	0	1	01	01	H5427_060_0	5	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5427	060	0	1	01	01	H5427_060_0	5	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5427	060	0	1	01	01	H5427_060_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	060	0	1	01	01	H5427_060_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	060	0	1	01	01	H5427_060_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	062	0	1	01	01	H5427_062_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5427	062	0	1	01	01	H5427_062_0	6	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5427	062	0	1	01	01	H5427_062_0	6	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5427	062	0	1	01	01	H5427_062_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5427	062	0	1	01	01	H5427_062_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	062	0	1	01	01	H5427_062_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	60.00								30.00			
H5427	062	0	1	01	01	H5427_062_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	062	0	1	01	01	H5427_062_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	070	0	1	01	01	H5427_070_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	070	0	1	01	01	H5427_070_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	070	0	1	01	01	H5427_070_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	070	0	1	01	01	H5427_070_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	070	0	1	01	01	H5427_070_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5427	070	0	1	01	01	H5427_070_0	6	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5427	070	0	1	01	01	H5427_070_0	6	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5427	070	0	1	01	01	H5427_070_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5427	072	0	1	01	01	H5427_072_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	072	0	1	01	01	H5427_072_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	072	0	1	01	01	H5427_072_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	072	0	1	01	01	H5427_072_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	076	0	1	01	01	H5427_076_0	6	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5427	076	0	1	01	01	H5427_076_0	6	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5427	076	0	1	01	01	H5427_076_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5427	076	0	1	01	01	H5427_076_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	076	0	1	01	01	H5427_076_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	076	0	1	01	01	H5427_076_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5427	076	0	1	01	01	H5427_076_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	076	0	1	01	01	H5427_076_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	077	0	1	01	01	H5427_077_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	077	0	1	01	01	H5427_077_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	077	0	1	01	01	H5427_077_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	077	0	1	01	01	H5427_077_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	080	0	1	01	01	H5427_080_0	7	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5427	080	0	1	01	01	H5427_080_0	7	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5427	080	0	1	01	01	H5427_080_0	7	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5427	080	0	1	01	01	H5427_080_0	7	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5427	080	0	1	01	01	H5427_080_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	080	0	1	01	01	H5427_080_0	7	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	080	0	1	01	01	H5427_080_0	7	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	080	0	1	01	01	H5427_080_0	7	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	081	0	1	01	01	H5427_081_0	9	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5427	081	0	1	01	01	H5427_081_0	9	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5427	081	0	1	01	01	H5427_081_0	9	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5427	081	0	1	01	01	H5427_081_0	9	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5427	081	0	1	01	01	H5427_081_0	9	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	081	0	1	01	01	H5427_081_0	9	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	081	0	1	01	01	H5427_081_0	9	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	081	0	1	01	01	H5427_081_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	082	0	1	01	01	H5427_082_0	7	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	082	0	1	01	01	H5427_082_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5427	082	0	1	01	01	H5427_082_0	7	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	082	0	1	01	01	H5427_082_0	7	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	083	0	1	01	01	H5427_083_0	7	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5427	083	0	1	01	01	H5427_083_0	7	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5427	083	0	1	01	01	H5427_083_0	7	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5427	083	0	1	01	01	H5427_083_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5428	001	0	1	01	01	H5428_001_0	7	2	4	1	Brand	000010	1	2	1	Brand	111000000010000000000	31	93								31											31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00											45.00			
H5428	001	0	1	01	01	H5428_001_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	31	93								31											31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
H5429	001	0	1	04	01	H5429_001_0	6	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	001	0	1	04	01	H5429_001_0	6	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5429	001	0	1	04	01	H5429_001_0	6	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	001	0	1	04	01	H5429_001_0	6	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5429	001	0	1	04	01	H5429_001_0	6	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	3.00	9.00	6.00							3.00		3.00	6.00	6.00							3.00			
H5429	005	0	1	04	01	H5429_005_0	6	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5429	005	0	1	04	01	H5429_005_0	6	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	3.00	9.00	6.00							3.00		3.00	6.00	6.00							3.00			
H5429	005	0	1	04	01	H5429_005_0	6	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	005	0	1	04	01	H5429_005_0	6	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5429	005	0	1	04	01	H5429_005_0	6	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	020	0	1	04	01	H5429_020_0	7	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	020	0	1	04	01	H5429_020_0	7	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5429	020	0	1	04	01	H5429_020_0	7	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	020	0	1	04	01	H5429_020_0	7	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	3.00	9.00	6.00							3.00		3.00	6.00	6.00							3.00			
H5429	020	0	1	04	01	H5429_020_0	7	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5429	059	0	1	04	01	H5429_059_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	14.00	14.00							7.00			
H5429	059	0	1	04	01	H5429_059_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	059	0	1	04	01	H5429_059_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5429	059	0	1	04	01	H5429_059_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	059	0	1	04	01	H5429_059_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5429	060	0	1	04	01	H5429_060_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5429	060	0	1	04	01	H5429_060_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	060	0	1	04	01	H5429_060_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5429	060	0	1	04	01	H5429_060_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	060	0	1	04	01	H5429_060_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5429	061	0	1	04	01	H5429_061_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5429	061	0	1	04	01	H5429_061_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	061	0	1	04	01	H5429_061_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5429	061	0	1	04	01	H5429_061_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	061	0	1	04	01	H5429_061_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	14.00	14.00							7.00			
H5429	062	0	1	04	01	H5429_062_0	6	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5429	062	0	1	04	01	H5429_062_0	6	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5429	062	0	1	04	01	H5429_062_0	6	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5429	062	0	1	04	01	H5429_062_0	6	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5429	062	0	1	04	01	H5429_062_0	6	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	3.00	9.00	6.00							3.00		3.00	6.00	6.00							3.00			
H5431	001	0	1	01	01	H5431_001_0	4	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	100010010010000000000				30			30			30											31		Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00	1	1	
H5431	001	0	1	01	01	H5431_001_0	4	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	100010010010000000000				30			30			30											31		Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00			
H5431	001	0	1	01	01	H5431_001_0	4	4	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5431	001	0	1	01	01	H5431_001_0	4	3	4	3	Preferred Brand	000010	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5431	001	0	1	01	01	H5431_001_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				25			25			25											25	Specialty																								
H5431	001	0	1	01	01	H5431_001_0	4	4	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100010010010000000000				30			30			30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				40.00			40.00			40.00											40.00			
H5431	001	0	1	01	01	H5431_001_0	4	3	4	1	Preferred Brand	000010	3	2	2	Preferred Brand	100010010010000000000				30			30			30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand				0.00			10.00			10.00											10.00			
H5431	001	0	1	01	01	H5431_001_0	4	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	100010010010000000000				30			30			30											31		Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											10.00			
H5431	001	0	1	01	01	H5431_001_0	4	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	100010010010000000000				30			30			30											31		Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											10.00	1	1	
H5431	001	0	1	01	01	H5431_001_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5431	002	0	1	01	01	H5431_002_0	4	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	100010010010000000000				30			30			30											31		Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											10.00			
H5431	002	0	1	01	01	H5431_002_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5431	002	0	1	01	01	H5431_002_0	4	4	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5431	002	0	1	01	01	H5431_002_0	4	3	4	3	Preferred Brand	000010	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5431	002	0	1	01	01	H5431_002_0	4	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	100010010010000000000				30			30			30											31		Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00			
H5431	002	0	1	01	01	H5431_002_0	4	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	100010010010000000000				30			30			30											31		Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00			0.00			0.00											0.00	1	1	
H5431	002	0	1	01	01	H5431_002_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	100010010010000000000				30			30			30											31		Specialty	1	Specialty				25			25			25											25	Specialty																								
H5431	002	0	1	01	01	H5431_002_0	4	4	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100010010010000000000				30			30			30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				40.00			40.00			40.00											40.00			
H5431	002	0	1	01	01	H5431_002_0	4	3	4	1	Preferred Brand	000010	3	2	2	Preferred Brand	100010010010000000000				30			30			30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand				0.00			10.00			10.00											10.00			
H5431	002	0	1	01	01	H5431_002_0	4	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	100010010010000000000				30			30			30											31		Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic				0.00			10.00			10.00											10.00	1	1	
H5431	005	0	1	01	01	H5431_005_0	4	3	4	1	Preferred Brand	000010	3	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	1	Preferred Brand	33									33											33	Preferred Brand																								
H5431	005	0	1	01	01	H5431_005_0	4	2	4	1	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	110000000010000000000	30									30											31		Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	0.00									0.00											0.00			
H5431	005	0	1	01	01	H5431_005_0	4	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	110000000010000000000	30									30											31		Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00									0.00											0.00			
H5431	005	0	1	01	01	H5431_005_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5431	005	0	1	01	01	H5431_005_0	4	4	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5431	005	0	1	01	01	H5431_005_0	4	3	4	3	Preferred Brand	000010	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5431	005	0	1	01	01	H5431_005_0	4	2	4	3	Non-Preferred Generic	000100	3	2	2	Non-Preferred Generic	110000000010000000000	30									30											31		Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	0.00									0.00											0.00	1	1	
H5431	005	0	1	01	01	H5431_005_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											31		Specialty	1	Specialty	33									33											33	Specialty																								
H5431	005	0	1	01	01	H5431_005_0	4	4	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	1	Non-Preferred Brand	33									33											33	Non-Preferred Brand																								
H5431	005	0	1	01	01	H5431_005_0	4	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	110000000010000000000	30									30											31		Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00									0.00											0.00	1	1	
H5433	001	0	1	01	01	H5433_001_0	7	2	4	3	Pre-ICL Tier 2, Tier #2	000010	1	2	1	Pre-ICL Tier 2, Tier #2																								Pre-ICL Tier 2, Tier #2		Pre-ICL Tier 2, Tier #2																						Pre-ICL Tier 2, Tier #2																						2		
H5433	001	0	1	01	01	H5433_001_0	7	1	4	3	Tier #1	010000	1	2	2	Tier #1	111000000001000000000	30	90									29										31	1	Tier #1	2	Tier #1																						Tier #1	0.00	0.00									0.00										0.00	1	1	
H5433	001	0	1	01	01	H5433_001_0	7	1	4	1	Tier #1	010000	1	2	2	Tier #1	111000000001000000000	30	90									29										31	1	Tier #1	2	Tier #1																						Tier #1	0.00	0.00									0.00										0.00			
H5433	001	0	1	01	01	H5433_001_0	7	2	4	1	Pre-ICL Tier 2, Tier #2	000010	1	2	1	Pre-ICL Tier 2, Tier #2	111000000001000000000	30	90									29										31	1	Pre-ICL Tier 2, Tier #2	2	Pre-ICL Tier 2, Tier #2																						Pre-ICL Tier 2, Tier #2	0.00	0.00									0.00										0.00			
H5434	002	0	1	04	01	H5434_002_0	6	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
H5434	002	0	1	04	01	H5434_002_0	6	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	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			
H5434	002	0	1	04	01	H5434_002_0	6	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	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			
H5434	002	0	1	04	01	H5434_002_0	6	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
H5435	014	0	1	09	04	H5435_014_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						230.00			240.00		80.00			
H5435	014	0	1	09	04	H5435_014_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5435	014	0	1	09	04	H5435_014_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5435	014	0	1	09	04	H5435_014_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5435	024	0	1	09	04	H5435_024_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5435	024	0	1	09	04	H5435_024_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5435	024	0	1	09	04	H5435_024_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						230.00			240.00		80.00			
H5435	024	0	1	09	04	H5435_024_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5435	027	0	1	09	04	H5435_027_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5435	027	0	1	09	04	H5435_027_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5435	027	0	1	09	04	H5435_027_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5435	027	0	1	09	04	H5435_027_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						230.00			240.00		80.00			
H5435	030	0	1	09	04	H5435_030_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5435	030	0	1	09	04	H5435_030_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5435	030	0	1	09	04	H5435_030_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5435	030	0	1	09	04	H5435_030_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						230.00			240.00		80.00			
H5435	031	0	1	09	04	H5435_031_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5435	031	0	1	09	04	H5435_031_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5435	031	0	1	09	04	H5435_031_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						230.00			240.00		80.00			
H5435	031	0	1	09	04	H5435_031_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5439	001	0	1	04	01	H5439_001_0	6	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5439	001	0	1	04	01	H5439_001_0	6	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	84.00	252.00	168.00							84.00					84.00	210.00	168.00	84.00	252.00	168.00	84.00			
H5439	001	0	1	04	01	H5439_001_0	6	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
H5439	001	0	1	04	01	H5439_001_0	6	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H5439	001	0	1	04	01	H5439_001_0	6	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5470	002	0	1	04	01	H5470_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5470	002	0	1	04	01	H5470_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H5470	002	0	1	04	01	H5470_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H5470	002	0	1	04	01	H5470_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5470	002	0	1	04	01	H5470_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5470	002	0	1	04	01	H5470_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H5470	002	0	1	04	01	H5470_002_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5470	004	0	1	04	01	H5470_004_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H5470	004	0	1	04	01	H5470_004_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5470	004	0	1	04	01	H5470_004_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5470	004	0	1	04	01	H5470_004_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5470	004	0	1	04	01	H5470_004_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H5470	004	0	1	04	01	H5470_004_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5470	004	0	1	04	01	H5470_004_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5470	004	0	1	04	01	H5470_004_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5470	005	0	1	04	01	H5470_005_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H5470	005	0	1	04	01	H5470_005_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5470	005	0	1	04	01	H5470_005_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5470	005	0	1	04	01	H5470_005_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5470	005	0	1	04	01	H5470_005_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H5470	005	0	1	04	01	H5470_005_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5470	005	0	1	04	01	H5470_005_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5470	005	0	1	04	01	H5470_005_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5470	007	0	1	04	01	H5470_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5470	007	0	1	04	01	H5470_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H5470	007	0	1	04	01	H5470_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5470	007	0	1	04	01	H5470_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5470	007	0	1	04	01	H5470_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5470	007	0	1	04	01	H5470_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H5470	007	0	1	04	01	H5470_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5470	007	0	1	04	01	H5470_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5507	001	0	1	04	01	H5507_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5507	001	0	1	04	01	H5507_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5507	001	0	1	04	01	H5507_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5507	001	0	1	04	01	H5507_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H5508	001	0	1	04	01	H5508_001_0	7	5	4	3	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents																								Non-Preferred Agents		Non-Preferred Agents																						Non-Preferred Agents																						2		
H5508	001	0	1	04	01	H5508_001_0	7	2	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H5508	001	0	1	04	01	H5508_001_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H5508	001	0	1	04	01	H5508_001_0	7	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5508	001	0	1	04	01	H5508_001_0	7	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5508	001	0	1	04	01	H5508_001_0	7	5	4	1	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Agents	2	Non-Preferred Agents																						Non-Preferred Agents	80.00	240.00								80.00		80.00	160.00								80.00			
H5508	001	0	1	04	01	H5508_001_0	7	4	4	1	Specialty	000010	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5508	001	0	1	04	01	H5508_001_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H5508	001	0	1	04	01	H5508_001_0	7	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H5508	001	0	1	04	01	H5508_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H5508	003	0	1	04	01	H5508_003_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H5508	003	0	1	04	01	H5508_003_0	5	5	4	1	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Agents	2	Non-Preferred Agents																						Non-Preferred Agents	80.00	240.00								80.00		80.00	160.00								80.00			
H5508	003	0	1	04	01	H5508_003_0	5	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H5508	003	0	1	04	01	H5508_003_0	5	4	4	1	Specialty	000010	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5508	003	0	1	04	01	H5508_003_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H5508	004	0	1	04	01	H5508_004_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H5508	004	0	1	04	01	H5508_004_0	6	5	4	1	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Agents	2	Non-Preferred Agents																						Non-Preferred Agents	80.00	240.00								80.00		80.00	160.00								80.00			
H5508	004	0	1	04	01	H5508_004_0	6	4	4	1	Specialty	000010	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5508	004	0	1	04	01	H5508_004_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H5508	004	0	1	04	01	H5508_004_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H5508	004	0	1	04	01	H5508_004_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5508	004	0	1	04	01	H5508_004_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H5508	004	0	1	04	01	H5508_004_0	6	5	4	3	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents																								Non-Preferred Agents		Non-Preferred Agents																						Non-Preferred Agents																						2		
H5508	004	0	1	04	01	H5508_004_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H5508	004	0	1	04	01	H5508_004_0	6	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5509	001	0	1	04	01	H5509_001_0	10	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	001	0	1	04	01	H5509_001_0	10	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	001	0	1	04	01	H5509_001_0	10	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	001	0	1	04	01	H5509_001_0	10	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H5509	003	0	1	04	01	H5509_003_0	8	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	003	0	1	04	01	H5509_003_0	8	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	003	0	1	04	01	H5509_003_0	8	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	003	0	1	04	01	H5509_003_0	8	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	6.00	18.00								6.00			15.00								6.00			
H5509	010	0	1	04	01	H5509_010_0	9	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	010	0	1	04	01	H5509_010_0	9	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	6.00	18.00								6.00			15.00								6.00			
H5509	010	0	1	04	01	H5509_010_0	9	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	010	0	1	04	01	H5509_010_0	9	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	011	0	1	04	01	H5509_011_0	9	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	011	0	1	04	01	H5509_011_0	9	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	011	0	1	04	01	H5509_011_0	9	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	011	0	1	04	01	H5509_011_0	9	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H5509	012	0	1	04	01	H5509_012_0	8	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H5509	012	0	1	04	01	H5509_012_0	8	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	012	0	1	04	01	H5509_012_0	8	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	012	0	1	04	01	H5509_012_0	8	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	013	0	1	04	01	H5509_013_0	9	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	013	0	1	04	01	H5509_013_0	9	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	013	0	1	04	01	H5509_013_0	9	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H5509	013	0	1	04	01	H5509_013_0	9	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	014	0	1	04	01	H5509_014_0	11	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5509	014	0	1	04	01	H5509_014_0	11	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	014	0	1	04	01	H5509_014_0	11	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	014	0	1	04	01	H5509_014_0	11	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H5509	015	0	1	04	01	H5509_015_0	8	3	4	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	100100	1	2	1	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND	2	NON-PREFERRED GENERIC/NON-PREFERRED BRAND																						NON-PREFERRED GENERIC/NON-PREFERRED BRAND	60.00	180.00								60.00			180.00								60.00			
H5509	015	0	1	04	01	H5509_015_0	8	2	4	1	PREFERRED BRAND	000001	1	2	2	PREFERRED BRAND	111000000010010000000	30	90								30			90								31	2	PREFERRED BRAND	2	PREFERRED BRAND																						PREFERRED BRAND	35.00	105.00								35.00			87.50								35.00			
H5509	015	0	1	04	01	H5509_015_0	8	1	4	1	PREFERRED GENERIC	001000	1	2	2	PREFERRED GENERIC	111000000010010000000	30	90								30			90								31	2	PREFERRED GENERIC	2	PREFERRED GENERIC																						PREFERRED GENERIC	7.00	21.00								7.00			17.50								7.00			
H5509	015	0	1	04	01	H5509_015_0	8	4	4	1	SPECIALTY- GENERIC AND BRAND	010010	1	1	2	SPECIALTY- GENERIC AND BRAND	110000000010000000000	30									30											31		SPECIALTY- GENERIC AND BRAND	1	SPECIALTY- GENERIC AND BRAND	33									33											33	SPECIALTY- GENERIC AND BRAND																								
H5516	001	0	1	04	01	H5516_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5516	001	0	1	04	01	H5516_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5516	001	0	1	04	01	H5516_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H5516	001	0	1	04	01	H5516_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5520	002	0	1	04	01	H5520_002_0	6	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5520	002	0	1	04	01	H5520_002_0	6	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5520	002	0	1	04	01	H5520_002_0	6	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H5520	002	0	1	04	01	H5520_002_0	6	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H5520	002	0	1	04	01	H5520_002_0	6	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	6.00	18.00	12.00							6.00					6.00	12.00	12.00	6.00	18.00	12.00	6.00			
H5520	004	0	1	04	01	H5520_004_0	6	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5520	004	0	1	04	01	H5520_004_0	6	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5520	004	0	1	04	01	H5520_004_0	6	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H5520	004	0	1	04	01	H5520_004_0	6	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H5520	004	0	1	04	01	H5520_004_0	6	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	6.00	18.00	12.00							6.00					6.00	12.00	12.00	6.00	18.00	12.00	6.00			
H5520	005	0	1	04	01	H5520_005_0	8	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5520	005	0	1	04	01	H5520_005_0	8	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5520	005	0	1	04	01	H5520_005_0	8	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H5520	005	0	1	04	01	H5520_005_0	8	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H5520	005	0	1	04	01	H5520_005_0	8	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	6.00	18.00	12.00							6.00					6.00	12.00	12.00	6.00	18.00	12.00	6.00			
H5520	006	0	1	04	01	H5520_006_0	7	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
H5520	006	0	1	04	01	H5520_006_0	7	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	6.00	18.00	12.00							6.00					6.00	12.00	12.00	6.00	18.00	12.00	6.00			
H5520	006	0	1	04	01	H5520_006_0	7	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	76.00	228.00	152.00							76.00					76.00	190.00	152.00	76.00	228.00	152.00	76.00			
H5520	006	0	1	04	01	H5520_006_0	7	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5520	006	0	1	04	01	H5520_006_0	7	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5520	009	0	1	04	01	H5520_009_0	5	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
H5520	009	0	1	04	01	H5520_009_0	5	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	70.00	210.00	140.00							70.00					70.00	175.00	140.00	70.00	210.00	140.00	70.00			
H5520	009	0	1	04	01	H5520_009_0	5	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5520	009	0	1	04	01	H5520_009_0	5	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5520	009	0	1	04	01	H5520_009_0	5	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H5520	010	0	1	04	01	H5520_010_0	7	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
H5520	010	0	1	04	01	H5520_010_0	7	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	70.00	210.00	140.00							70.00					70.00	175.00	140.00	70.00	210.00	140.00	70.00			
H5520	010	0	1	04	01	H5520_010_0	7	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
H5520	010	0	1	04	01	H5520_010_0	7	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
H5520	010	0	1	04	01	H5520_010_0	7	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
H5521	011	0	1	04	01	H5521_011_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					76.00			114.00		38.00			
H5521	011	0	1	04	01	H5521_011_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					64.00			96.00		32.00			
H5521	011	0	1	04	01	H5521_011_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5521	011	0	1	04	01	H5521_011_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5521	011	0	1	04	01	H5521_011_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				9.00	22.50		9.00	27.00			9.00					18.00			27.00		9.00			
H5521	012	0	1	04	01	H5521_012_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5521	012	0	1	04	01	H5521_012_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5521	012	0	1	04	01	H5521_012_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5521	012	0	1	04	01	H5521_012_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				6.00	15.00		6.00	18.00			6.00					12.00			18.00		6.00			
H5521	012	0	1	04	01	H5521_012_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H5521	013	0	1	04	01	H5521_013_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	72.00	216.00									72.00					144.00			216.00		72.00			
H5521	013	0	1	04	01	H5521_013_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	013	0	1	04	01	H5521_013_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H5521	013	0	1	04	01	H5521_013_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00			
H5521	013	0	1	04	01	H5521_013_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	014	0	1	04	01	H5521_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																						2		
H5521	014	0	1	04	01	H5521_014_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5521	014	0	1	04	01	H5521_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																						2		
H5521	014	0	1	04	01	H5521_014_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5521	014	0	1	04	01	H5521_014_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H5521	014	0	1	04	01	H5521_014_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5521	014	0	1	04	01	H5521_014_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	014	0	1	04	01	H5521_014_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	014	0	1	04	01	H5521_014_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	014	0	1	04	01	H5521_014_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	015	0	1	04	01	H5521_015_0	6	5	3	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5521	015	0	1	04	01	H5521_015_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00			
H5521	015	0	1	04	01	H5521_015_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5521	015	0	1	04	01	H5521_015_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5521	015	0	1	04	01	H5521_015_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00			
H5521	016	0	1	04	01	H5521_016_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	016	0	1	04	01	H5521_016_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	016	0	1	04	01	H5521_016_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H5521	016	0	1	04	01	H5521_016_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5521	016	0	1	04	01	H5521_016_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H5521	017	0	1	04	01	H5521_017_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5521	017	0	1	04	01	H5521_017_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	017	0	1	04	01	H5521_017_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H5521	017	0	1	04	01	H5521_017_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	017	0	1	04	01	H5521_017_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	018	0	1	04	01	H5521_018_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00			
H5521	018	0	1	04	01	H5521_018_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					56.00			84.00		28.00			
H5521	018	0	1	04	01	H5521_018_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					54.00			81.00		27.00			
H5521	018	0	1	04	01	H5521_018_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	11.00	33.00									11.00					22.00			33.00		11.00			
H5521	018	0	1	04	01	H5521_018_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	020	0	1	04	01	H5521_020_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	020	0	1	04	01	H5521_020_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					68.00			102.00		34.00			
H5521	020	0	1	04	01	H5521_020_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5521	020	0	1	04	01	H5521_020_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H5521	020	0	1	04	01	H5521_020_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	021	0	1	04	01	H5521_021_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H5521	021	0	1	04	01	H5521_021_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	021	0	1	04	01	H5521_021_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	021	0	1	04	01	H5521_021_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H5521	021	0	1	04	01	H5521_021_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5521	022	0	1	04	01	H5521_022_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00			
H5521	022	0	1	04	01	H5521_022_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	022	0	1	04	01	H5521_022_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00			
H5521	022	0	1	04	01	H5521_022_0	3	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00			
H5521	022	0	1	04	01	H5521_022_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00			
H5521	026	0	1	04	01	H5521_026_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H5521	026	0	1	04	01	H5521_026_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	026	0	1	04	01	H5521_026_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	026	0	1	04	01	H5521_026_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	026	0	1	04	01	H5521_026_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5521	027	0	1	04	01	H5521_027_0	8	5	3	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	027	0	1	04	01	H5521_027_0	8	4	3	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	74.00	222.00									74.00					148.00			222.00		74.00			
H5521	027	0	1	04	01	H5521_027_0	8	3	3	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					68.00			102.00		34.00			
H5521	027	0	1	04	01	H5521_027_0	8	1	3	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5521	027	0	1	04	01	H5521_027_0	8	2	3	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	028	0	1	04	01	H5521_028_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	028	0	1	04	01	H5521_028_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	028	0	1	04	01	H5521_028_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00			
H5521	028	0	1	04	01	H5521_028_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	028	0	1	04	01	H5521_028_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	82.00	246.00									82.00					164.00			246.00		82.00			
H5521	029	0	1	04	01	H5521_029_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	029	0	1	04	01	H5521_029_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	029	0	1	04	01	H5521_029_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	82.00	246.00									82.00					164.00			246.00		82.00			
H5521	029	0	1	04	01	H5521_029_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H5521	029	0	1	04	01	H5521_029_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	030	0	1	04	01	H5521_030_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00			
H5521	030	0	1	04	01	H5521_030_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	38.00	114.00									38.00					76.00			114.00		38.00			
H5521	030	0	1	04	01	H5521_030_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00									45.00					90.00			135.00		45.00			
H5521	030	0	1	04	01	H5521_030_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	90.00	270.00									90.00					180.00			270.00		90.00			
H5521	030	0	1	04	01	H5521_030_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	031	0	1	04	01	H5521_031_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H5521	031	0	1	04	01	H5521_031_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					8.00			12.00		4.00			
H5521	031	0	1	04	01	H5521_031_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	031	0	1	04	01	H5521_031_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	031	0	1	04	01	H5521_031_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	032	0	1	04	01	H5521_032_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					74.00			111.00		37.00			
H5521	032	0	1	04	01	H5521_032_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	032	0	1	04	01	H5521_032_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	032	0	1	04	01	H5521_032_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	032	0	1	04	01	H5521_032_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	033	0	1	04	01	H5521_033_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	033	0	1	04	01	H5521_033_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	033	0	1	04	01	H5521_033_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00			
H5521	033	0	1	04	01	H5521_033_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	32.00	96.00									32.00					64.00			96.00		32.00			
H5521	033	0	1	04	01	H5521_033_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5521	034	0	1	04	01	H5521_034_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	034	0	1	04	01	H5521_034_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	034	0	1	04	01	H5521_034_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H5521	034	0	1	04	01	H5521_034_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	034	0	1	04	01	H5521_034_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	035	0	1	04	01	H5521_035_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H5521	035	0	1	04	01	H5521_035_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				8.00	20.00		8.00	24.00			8.00					16.00			24.00		8.00			
H5521	035	0	1	04	01	H5521_035_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5521	035	0	1	04	01	H5521_035_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H5521	035	0	1	04	01	H5521_035_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5521	035	0	1	04	01	H5521_035_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5521	035	0	1	04	01	H5521_035_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5521	035	0	1	04	01	H5521_035_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5521	035	0	1	04	01	H5521_035_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																						2		
H5521	035	0	1	04	01	H5521_035_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5521	036	0	1	04	01	H5521_036_0	6	1	3	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				11.00	27.50		11.00	33.00			11.00					22.00			33.00		11.00			
H5521	036	0	1	04	01	H5521_036_0	6	2	3	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				27.00	67.50		27.00	81.00			27.00					54.00			81.00		27.00			
H5521	036	0	1	04	01	H5521_036_0	6	3	3	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5521	036	0	1	04	01	H5521_036_0	6	4	3	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	036	0	1	04	01	H5521_036_0	6	5	3	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5521	037	0	1	04	01	H5521_037_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	037	0	1	04	01	H5521_037_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	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	037	0	1	04	01	H5521_037_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5521	037	0	1	04	01	H5521_037_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5521	037	0	1	04	01	H5521_037_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5521	038	0	1	04	01	H5521_038_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H5521	038	0	1	04	01	H5521_038_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5521	038	0	1	04	01	H5521_038_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H5521	038	0	1	04	01	H5521_038_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H5521	038	0	1	04	01	H5521_038_0	6	4	4	1	Tier 4 - Non-Preferred Brand	000100	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5521	038	0	1	04	01	H5521_038_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5521	038	0	1	04	01	H5521_038_0	6	4	4	3	Tier 4 - Non-Preferred Brand	000100	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5521	038	0	1	04	01	H5521_038_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																						2		
H5521	038	0	1	04	01	H5521_038_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H5521	038	0	1	04	01	H5521_038_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5521	039	0	1	04	01	H5521_039_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	039	0	1	04	01	H5521_039_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5521	039	0	1	04	01	H5521_039_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	039	0	1	04	01	H5521_039_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	039	0	1	04	01	H5521_039_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	040	0	1	04	01	H5521_040_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00			
H5521	040	0	1	04	01	H5521_040_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5521	040	0	1	04	01	H5521_040_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	040	0	1	04	01	H5521_040_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	75.00	225.00									75.00					150.00			225.00		75.00			
H5521	040	0	1	04	01	H5521_040_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	041	0	1	04	01	H5521_041_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	041	0	1	04	01	H5521_041_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	041	0	1	04	01	H5521_041_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H5521	041	0	1	04	01	H5521_041_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	041	0	1	04	01	H5521_041_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5521	041	0	1	04	01	H5521_041_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5521	041	0	1	04	01	H5521_041_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5521	041	0	1	04	01	H5521_041_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5521	041	0	1	04	01	H5521_041_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																						2		
H5521	041	0	1	04	01	H5521_041_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	043	0	1	04	01	H5521_043_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					54.00			81.00		27.00			
H5521	043	0	1	04	01	H5521_043_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5521	043	0	1	04	01	H5521_043_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	043	0	1	04	01	H5521_043_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H5521	043	0	1	04	01	H5521_043_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	044	0	1	04	01	H5521_044_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5521	044	0	1	04	01	H5521_044_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00									40.00					80.00			120.00		40.00			
H5521	044	0	1	04	01	H5521_044_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5521	044	0	1	04	01	H5521_044_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																						2		
H5521	044	0	1	04	01	H5521_044_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5521	044	0	1	04	01	H5521_044_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5521	044	0	1	04	01	H5521_044_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	044	0	1	04	01	H5521_044_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5521	044	0	1	04	01	H5521_044_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	044	0	1	04	01	H5521_044_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	045	0	1	04	01	H5521_045_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5521	045	0	1	04	01	H5521_045_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5521	045	0	1	04	01	H5521_045_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H5521	045	0	1	04	01	H5521_045_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5521	045	0	1	04	01	H5521_045_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H5522	001	0	1	04	01	H5522_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00			15.00								6.00			
H5522	001	0	1	04	01	H5522_001_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	38.00	114.00								38.00			95.00								38.00			
H5522	001	0	1	04	01	H5522_001_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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			
H5522	001	0	1	04	01	H5522_001_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	001	0	1	04	01	H5522_001_0	7	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00			15.00								6.00	1	1	
H5522	001	0	1	04	01	H5522_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																						2		
H5522	001	0	1	04	01	H5522_001_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	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																						2		
H5522	001	0	1	04	01	H5522_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																						2		
H5522	002	0	1	04	01	H5522_002_0	7	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00								2.00			5.00								2.00	1	1	
H5522	002	0	1	04	01	H5522_002_0	7	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	002	0	1	04	01	H5522_002_0	7	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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			
H5522	002	0	1	04	01	H5522_002_0	7	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H5522	002	0	1	04	01	H5522_002_0	7	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00								2.00			5.00								2.00			
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																						2		
H5522	002	0	1	04	01	H5522_002_0	7	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	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																						2		
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																						2		
H5522	003	0	1	04	01	H5522_003_0	8	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand																						Tier 3 - Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H5522	003	0	1	04	01	H5522_003_0	8	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	003	0	1	04	01	H5522_003_0	8	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00			15.00								6.00	1	1	
H5522	003	0	1	04	01	H5522_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																						2		
H5522	003	0	1	04	01	H5522_003_0	8	3	4	3	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	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																						2		
H5522	003	0	1	04	01	H5522_003_0	8	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	37.00	111.00								37.00			92.50								37.00			
H5522	003	0	1	04	01	H5522_003_0	8	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00			15.00								6.00			
H5522	003	0	1	04	01	H5522_003_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																						2		
H5522	004	0	1	04	01	H5522_004_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	004	0	1	04	01	H5522_004_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	37.00	111.00								37.00			92.50								37.00			
H5522	004	0	1	04	01	H5522_004_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00								6.00			15.00								6.00			
H5522	005	0	1	04	01	H5522_005_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	41.00	123.00								41.00			102.50								41.00			
H5522	005	0	1	04	01	H5522_005_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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	005	0	1	04	01	H5522_005_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	005	0	1	04	01	H5522_005_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00								4.00			10.00								4.00			
H5522	007	0	1	04	01	H5522_007_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	007	0	1	04	01	H5522_007_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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	007	0	1	04	01	H5522_007_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00								4.00			10.00								4.00			
H5522	007	0	1	04	01	H5522_007_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H5522	008	0	1	04	01	H5522_008_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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	008	0	1	04	01	H5522_008_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5522	008	0	1	04	01	H5522_008_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H5522	008	0	1	04	01	H5522_008_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00								4.00			10.00								4.00			
H5522	009	0	1	04	01	H5522_009_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00								4.00			10.00								4.00			
H5522	009	0	1	04	01	H5522_009_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	40.00	120.00								40.00			100.00								40.00			
H5522	009	0	1	04	01	H5522_009_0	6	3	4	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	000101	1	2	1	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Non-Preferred Generic/Non-Preferred Brand	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	009	0	1	04	01	H5522_009_0	6	4	4	1	Tier 4 - Specialty Drugs	010010	1	1	2	Tier 4 - Specialty Drugs	110000000010000000000	30									30											31		Tier 4 - Specialty Drugs	1	Tier 4 - Specialty Drugs	33									33											33	Tier 4 - Specialty Drugs																								
H5525	004	0	1	04	01	H5525_004_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H5525	004	0	1	04	01	H5525_004_0	7	2	4	1	Non-Preferred Generic and Preferred Brand	000111	1	2	2	Non-Preferred Generic and Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic and Preferred Brand	2	Non-Preferred Generic and Preferred Brand																						Non-Preferred Generic and Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H5525	004	0	1	04	01	H5525_004_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5525	004	0	1	04	01	H5525_004_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5525	004	0	1	04	01	H5525_004_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H5525	004	0	1	04	01	H5525_004_0	7	2	4	3	Non-Preferred Generic and Preferred Brand	000111	1	2	2	Non-Preferred Generic and Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic and Preferred Brand	2	Non-Preferred Generic and Preferred Brand																						Non-Preferred Generic and Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H5525	004	0	1	04	01	H5525_004_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5525	004	0	1	04	01	H5525_004_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5526	003	0	1	04	01	H5526_003_0	9	4	4	1	Speciality Injectables	100001	1	1	2	Speciality Injectables	111000000010110000000	30	90								30		30	90								31	2	Speciality Injectables	1	Speciality Injectables	30	30								30		30	25								30	Speciality Injectables																								
H5526	003	0	1	04	01	H5526_003_0	9	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	42								50	Non-Preferred																								
H5526	003	0	1	04	01	H5526_003_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00			
H5526	003	0	1	04	01	H5526_003_0	9	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H5526	004	0	1	04	01	H5526_004_0	9	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	6.50	19.50								6.50		6.50	16.25								6.50			
H5526	004	0	1	04	01	H5526_004_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	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	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H5526	004	0	1	04	01	H5526_004_0	9	3	4	1	Non-Preferred Brand/Generic	100100	1	2	1	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Brand/Generic	1	Non-Preferred Brand/Generic	50	50								50		50	42								50	Non-Preferred Brand/Generic																								
H5526	007	0	1	04	01	H5526_007_0	8	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H5526	007	0	1	04	01	H5526_007_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	87.50								35.00			
H5526	007	0	1	04	01	H5526_007_0	8	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred	1	Non-Preferred	50	50								50		50	42								50	Non-Preferred																								
H5526	007	0	1	04	01	H5526_007_0	8	4	4	1	Speciality Injectables	100001	1	1	2	Speciality Injectables	111000000010110000000	30	90								30		30	90								31	2	Speciality Injectables	1	Speciality Injectables	30	30								30		30	25								30	Speciality Injectables																								
H5526	007	0	1	04	01	H5526_007_0	8	1	4	3	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	2	00001000
H5526	007	0	1	04	01	H5526_007_0	8	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5526	007	0	1	04	01	H5526_007_0	8	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5526	007	0	1	04	01	H5526_007_0	8	4	4	3	Speciality Injectables	100001	1	1	2	Speciality Injectables																								Speciality Injectables		Speciality Injectables																						Speciality Injectables																						2		
H5526	008	0	1	04	01	H5526_008_0	12	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5526	008	0	1	04	01	H5526_008_0	12	1	4	3	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	2	00001000
H5526	008	0	1	04	01	H5526_008_0	12	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H5526	008	0	1	04	01	H5526_008_0	12	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H5526	008	0	1	04	01	H5526_008_0	12	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	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	12	3	4	1	Non-Preferred Brand/Generic	100100	1	2	1	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Brand/Generic	1	Non-Preferred Brand/Generic	50	50								50		50	42								50	Non-Preferred Brand/Generic																								
H5526	008	0	1	04	01	H5526_008_0	12	3	4	3	Non-Preferred Brand/Generic	100100	1	2	1																																																																							2		
H5526	008	0	1	04	01	H5526_008_0	12	4	4	3	Specialty Injectables	100001	1	1	2	Specialty Injectables																								Specialty Injectables		Specialty Injectables																						Specialty Injectables																						2		
H5526	010	0	1	04	01	H5526_010_0	10	4	4	3	Specialty Injectables	100001	1	1	2	Specialty Injectables																								Specialty Injectables		Specialty Injectables																						Specialty Injectables																						2		
H5526	010	0	1	04	01	H5526_010_0	10	3	4	3	Non-Preferred Brand/Generic	100100	1	2	1	Non-Preferred Brand/Generic																								Non-Preferred Brand/Generic		Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																						2		
H5526	010	0	1	04	01	H5526_010_0	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00	1	1	
H5526	010	0	1	04	01	H5526_010_0	10	1	4	3	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	1	
H5526	010	0	1	04	01	H5526_010_0	10	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H5526	010	0	1	04	01	H5526_010_0	10	3	4	1	Non-Preferred Brand/Generic	100100	1	2	1	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Brand/Generic	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	10	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00			
H5526	011	0	1	04	01	H5526_011_0	10	1	4	1	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00			
H5526	011	0	1	04	01	H5526_011_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00			
H5526	011	0	1	04	01	H5526_011_0	10	3	4	1	Non-Preferred Brand/Generic	100100	1	2	1	Non-Preferred Brand/Generic	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Brand/Generic	2	Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic	40.00	120.00								40.00		40.00	100.00								40.00			
H5526	011	0	1	04	01	H5526_011_0	10	4	4	1	Specialty Injectables	100001	1	1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	30	30								30		30	25								30	Specialty Injectables																								
H5526	011	0	1	04	01	H5526_011_0	10	1	4	3	Formulary Generic	001000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	2	Formulary Generic	2	Formulary Generic																						Formulary Generic	5.00	15.00								5.00		5.00	12.50								5.00	1	1	
H5526	011	0	1	04	01	H5526_011_0	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00		25.00	62.50								25.00	1	1	
H5526	011	0	1	04	01	H5526_011_0	10	3	4	3	Non-Preferred Brand/Generic	100100	1	2	1	Non-Preferred Brand/Generic																								Non-Preferred Brand/Generic		Non-Preferred Brand/Generic																						Non-Preferred Brand/Generic																						2		
H5526	011	0	1	04	01	H5526_011_0	10	4	4	3	Specialty Injectables	100001	1	1	2	Specialty Injectables																								Specialty Injectables		Specialty Injectables																						Specialty Injectables																						2		
H5528	002	0	1	04	01	H5528_002_0	4	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
H5528	002	0	1	04	01	H5528_002_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				33	33	33	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	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2				20.00	40.00	60.00	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	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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			
H5528	003	0	1	04	01	H5528_003_0	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				7.00	14.00	21.00	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	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5528	003	0	1	04	01	H5528_003_0	4	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5528	003	0	1	04	01	H5528_003_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2				20.00	40.00	60.00	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	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
H5528	003	0	1	04	01	H5528_003_0	4	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				7.00	14.00	21.00	7.00	21.00	21.00	7.00		7.00	14.00	14.00							7.00	1	1	
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																						2		
H5528	003	0	1	04	01	H5528_003_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																								
H5528	005	0	1	04	01	H5528_005_0	5	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
H5528	005	0	1	04	01	H5528_005_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																								
H5528	005	0	1	04	01	H5528_005_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2				20.00	40.00	60.00	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	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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			
H5528	008	0	1	04	01	H5528_008_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H5528	008	0	1	04	01	H5528_008_0	5	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5528	008	0	1	04	01	H5528_008_0	5	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5528	008	0	1	04	01	H5528_008_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																								
H5528	008	0	1	04	01	H5528_008_0	5	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
H5528	008	0	1	04	01	H5528_008_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2				20.00	40.00	60.00	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	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				7.00	14.00	21.00	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	5	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				7.00	14.00	21.00	7.00	21.00	21.00	7.00		7.00	14.00	14.00							7.00	1	1	
H5528	010	0	1	04	01	H5528_010_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																								
H5528	010	0	1	04	01	H5528_010_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2				20.00	40.00	60.00	20.00	60.00	60.00	20.00		20.00	40.00	40.00							20.00			
H5528	010	0	1	04	01	H5528_010_0	7	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
H5528	010	0	1	04	01	H5528_010_0	7	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	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			
H5528	011	0	1	04	01	H5528_011_0	4	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				7.00	14.00	21.00	7.00	21.00	21.00	7.00		7.00	14.00	14.00							7.00	1	1	
H5528	011	0	1	04	01	H5528_011_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				33	33	33	33	33	33	33		33	33	33							33	Tier 4																								
H5528	011	0	1	04	01	H5528_011_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2				20.00	40.00	60.00	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	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				7.00	14.00	21.00	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	3	4	1	Tier 3	100100	1	2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				50	50	50	50	50	50	50		50	50	50							50	Tier 3																								
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																						2		
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																						2		
H5528	011	0	1	04	01	H5528_011_0	4	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5528	013	0	1	04	01	H5528_013_0	3	4	2	1	Tier 4	010010		1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H5528	013	0	1	04	01	H5528_013_0	3	3	2	1	Tier 3	100100		2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																								
H5528	013	0	1	04	01	H5528_013_0	3	2	2	1	Tier 2	000001		2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																								
H5528	013	0	1	04	01	H5528_013_0	3	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
H5528	014	0	1	04	01	H5528_014_0	3	4	2	1	Tier 4	010010		1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H5528	014	0	1	04	01	H5528_014_0	3	2	2	1	Tier 2	000001		2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																								
H5528	014	0	1	04	01	H5528_014_0	3	3	2	1	Tier 3	100100		2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																								
H5528	014	0	1	04	01	H5528_014_0	3	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
H5528	018	0	1	04	01	H5528_018_0	4	3	2	1	Tier 3	100100		2	1	Tier 3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 3	1	Tier 3				40	40	40	40	40	40	40		40	40	40							40	Tier 3																								
H5528	018	0	1	04	01	H5528_018_0	4	4	2	1	Tier 4	010010		1	2	Tier 4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 4	1	Tier 4				25	25	25	25	25	25	25		25	25	25							25	Tier 4																								
H5528	018	0	1	04	01	H5528_018_0	4	2	2	1	Tier 2	000001		2	2	Tier 2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 2	1	Tier 2				25	25	25	25	25	25	25		25	25	25							25	Tier 2																								
H5528	018	0	1	04	01	H5528_018_0	4	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
H5529	001	0	1	04	01	H5529_001_0	12	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5529	001	0	1	04	01	H5529_001_0	12	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5529	001	0	1	04	01	H5529_001_0	12	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5529	001	0	1	04	01	H5529_001_0	12	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5529	001	0	1	04	01	H5529_001_0	12	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5529	001	0	1	04	01	H5529_001_0	12	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5529	001	0	1	04	01	H5529_001_0	12	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5529	001	0	1	04	01	H5529_001_0	12	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5529	001	0	1	04	01	H5529_001_0	12	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5529	001	0	1	04	01	H5529_001_0	12	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5529	004	0	1	04	01	H5529_004_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5529	004	0	1	04	01	H5529_004_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5529	004	0	1	04	01	H5529_004_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5529	004	0	1	04	01	H5529_004_0	9	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5529	004	0	1	04	01	H5529_004_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5529	004	0	1	04	01	H5529_004_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5529	004	0	1	04	01	H5529_004_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5529	004	0	1	04	01	H5529_004_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5529	004	0	1	04	01	H5529_004_0	9	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5529	004	0	1	04	01	H5529_004_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5530	001	0	1	04	01	H5530_001_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5530	001	0	1	04	01	H5530_001_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5530	001	0	1	04	01	H5530_001_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5530	001	0	1	04	01	H5530_001_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5530	001	0	1	04	01	H5530_001_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5530	001	0	1	04	01	H5530_001_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5530	001	0	1	04	01	H5530_001_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5530	001	0	1	04	01	H5530_001_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5530	001	0	1	04	01	H5530_001_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5530	001	0	1	04	01	H5530_001_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5530	004	0	1	04	01	H5530_004_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5530	004	0	1	04	01	H5530_004_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5530	004	0	1	04	01	H5530_004_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5530	004	0	1	04	01	H5530_004_0	9	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5530	004	0	1	04	01	H5530_004_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5530	004	0	1	04	01	H5530_004_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5530	004	0	1	04	01	H5530_004_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5530	004	0	1	04	01	H5530_004_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5530	004	0	1	04	01	H5530_004_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5530	004	0	1	04	01	H5530_004_0	9	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5532	001	0	1	04	01	H5532_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5532	001	0	1	04	01	H5532_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H5532	001	0	1	04	01	H5532_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5532	001	0	1	04	01	H5532_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5533	002	0	1	04	01	H5533_002_0	10	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	85.00	255.00								85.00			212.50								85.00			
H5533	002	0	1	04	01	H5533_002_0	10	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H5533	002	0	1	04	01	H5533_002_0	10	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H5533	002	0	1	04	01	H5533_002_0	10	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H5533	002	0	1	04	01	H5533_002_0	10	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
H5533	002	0	1	04	01	H5533_002_0	10	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand																								Tier 3 - Non-Preferred Brand		Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																						2		
H5533	002	0	1	04	01	H5533_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																						2		
H5533	002	0	1	04	01	H5533_002_0	10	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H5533	003	0	1	04	01	H5533_003_0	7	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H5533	003	0	1	04	01	H5533_003_0	7	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H5533	003	0	1	04	01	H5533_003_0	7	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H5533	003	0	1	04	01	H5533_003_0	7	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H5549	004	0	1	01	01	H5549_004_0	4	1	4	1	TIER #1	010000	1	2	2	TIER #1	111000000010010000000	30	90								30			90								31	1	TIER #1	2	TIER #1																						TIER #1	5.00	15.00								5.00			12.50								5.00			
H5549	004	0	1	01	01	H5549_004_0	4	4	4	1	TIER #4	100000	1	1	1	TIER #4	111000000010010000000	30	90								30			90								31	2	TIER #4	1	TIER #4	25	25								25			25								25	TIER #4																								
H5549	004	0	1	01	01	H5549_004_0	4	3	4	1	TIER #3	100000	1	2	2	TIER #3	111000000010010000000	30	90								30			90								31	1	TIER #3	2	TIER #3																						TIER #3	60.00	180.00								60.00			150.00								60.00			
H5549	004	0	1	01	01	H5549_004_0	4	2	4	1	TIER #2	000001	1	2	2	TIER #2	111000000010010000000	30	90								30			90								31	1	TIER #2	2	TIER #2																						TIER #2	30.00	90.00								30.00			75.00								30.00			
H5575	006	0	1	01	01	H5575_006_0	6	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5575	006	0	1	01	01	H5575_006_0	6	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5575	006	0	1	01	01	H5575_006_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5575	006	0	1	01	01	H5575_006_0	6	1	4	3	generic	010000	1	2	2	generic	111000000001010000000	31	90									29		90								31	1	generic	2	generic																						generic	5.00	10.00									5.00		10.00								5.00	1	1	
H5575	006	0	1	01	01	H5575_006_0	6	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001100000000	31	90									29	31									31	1	Specialty	1	Specialty	33	33									33	33									33	Specialty																								
H5575	006	0	1	01	01	H5575_006_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	31	90									29		90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	130.00									65.00		130.00								65.00			
H5575	006	0	1	01	01	H5575_006_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									30.00		60.00								30.00			
H5575	006	0	1	01	01	H5575_006_0	6	1	4	1	generic	010000	1	2	2	generic	111000000001010000000	31	90									29		90								31	1	generic	2	generic																						generic	5.00	10.00									5.00		10.00								5.00			
H5575	007	0	1	01	01	H5575_007_0	6	3	4	3	Non-Preferred	100000	1	2	2	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5575	007	0	1	01	01	H5575_007_0	6	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5575	007	0	1	01	01	H5575_007_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5575	007	0	1	01	01	H5575_007_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00	1	1	
H5575	007	0	1	01	01	H5575_007_0	6	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001010000000	31	90									29		90								31	1	Specialty	1	Specialty	33	33									33		33								33	Specialty																								
H5575	007	0	1	01	01	H5575_007_0	6	3	4	1	Non-Preferred	100000	1	2	2	Non-Preferred	111000000001010000000	31	90									29		90								31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	65.00	130.00									65.00		130.00								65.00			
H5575	007	0	1	01	01	H5575_007_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									30.00		60.00								30.00			
H5575	007	0	1	01	01	H5575_007_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00			
H5576	005	0	1	02	01	H5576_005_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	90								31			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00			
H5576	005	0	1	02	01	H5576_005_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	90								31			90								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
H5576	005	0	1	02	01	H5576_005_0	7	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	31	90								31			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H5576	005	0	1	02	01	H5576_005_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H5576	006	0	1	02	01	H5576_006_0	7	4	4	3	Tier 4	100000	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5576	006	0	1	02	01	H5576_006_0	7	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5576	006	0	1	02	01	H5576_006_0	7	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H5576	006	0	1	02	01	H5576_006_0	7	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	31	90								31			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H5576	006	0	1	02	01	H5576_006_0	7	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	90								31			90								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
H5576	006	0	1	02	01	H5576_006_0	7	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00	1	1	
H5576	006	0	1	02	01	H5576_006_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H5576	006	0	1	02	01	H5576_006_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	90								31			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00			
H5576	007	0	1	02	01	H5576_007_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			30.00								10.00			
H5576	007	0	1	02	01	H5576_007_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	90								31			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00			
H5576	007	0	1	02	01	H5576_007_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	90								31			90								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
H5576	007	0	1	02	01	H5576_007_0	5	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	31	90								31			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H5576	009	0	1	02	01	H5576_009_0	6	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	90								31			90								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
H5576	009	0	1	02	01	H5576_009_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	90								31			90								31	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			120.00								40.00			
H5576	009	0	1	02	01	H5576_009_0	6	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	90								31			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
H5576	009	0	1	02	01	H5576_009_0	6	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	31	90								31			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H5578	002	0	1	01	01	H5578_002_0	10	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5578	002	0	1	01	01	H5578_002_0	10	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5578	002	0	1	01	01	H5578_002_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																						2		
H5578	002	0	1	01	01	H5578_002_0	10	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5578	002	0	1	01	01	H5578_002_0	10	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5578	002	0	1	01	01	H5578_002_0	10	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5578	002	0	1	01	01	H5578_002_0	10	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5578	002	0	1	01	01	H5578_002_0	10	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5578	002	0	1	01	01	H5578_002_0	10	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00			
H5578	002	0	1	01	01	H5578_002_0	10	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5578	006	0	1	01	01	H5578_006_0	11	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5578	006	0	1	01	01	H5578_006_0	11	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5578	006	0	1	01	01	H5578_006_0	11	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																						2		
H5578	006	0	1	01	01	H5578_006_0	11	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5578	006	0	1	01	01	H5578_006_0	11	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5578	006	0	1	01	01	H5578_006_0	11	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5578	006	0	1	01	01	H5578_006_0	11	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5578	006	0	1	01	01	H5578_006_0	11	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5578	006	0	1	01	01	H5578_006_0	11	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5578	006	0	1	01	01	H5578_006_0	11	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	7.50	22.50								7.50			15.00								7.50			
H5578	009	0	1	01	01	H5578_009_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H5578	009	0	1	01	01	H5578_009_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H5578	009	0	1	01	01	H5578_009_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5578	009	0	1	01	01	H5578_009_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5578	009	0	1	01	01	H5578_009_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H5578	009	0	1	01	01	H5578_009_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5578	009	0	1	01	01	H5578_009_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5578	009	0	1	01	01	H5578_009_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5578	009	0	1	01	01	H5578_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																						2		
H5578	009	0	1	01	01	H5578_009_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5578	012	0	1	01	01	H5578_012_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5578	012	0	1	01	01	H5578_012_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5578	012	0	1	01	01	H5578_012_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5578	012	0	1	01	01	H5578_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																						2		
H5578	012	0	1	01	01	H5578_012_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5578	012	0	1	01	01	H5578_012_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5578	012	0	1	01	01	H5578_012_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5578	012	0	1	01	01	H5578_012_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5578	012	0	1	01	01	H5578_012_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5578	012	0	1	01	01	H5578_012_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	20.00	60.00								20.00			40.00								20.00			
H5578	013	0	1	01	01	H5578_013_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H5578	013	0	1	01	01	H5578_013_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5578	013	0	1	01	01	H5578_013_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5578	013	0	1	01	01	H5578_013_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5578	013	0	1	01	01	H5578_013_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H5578	013	0	1	01	01	H5578_013_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5578	013	0	1	01	01	H5578_013_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5578	013	0	1	01	01	H5578_013_0	6	3	4	3	Tier 3 - Preferred Brand	000001	1	2	2																																																																							2		
H5578	013	0	1	01	01	H5578_013_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H5578	013	0	1	01	01	H5578_013_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5587	001	0	1	01	01	H5587_001_0	11	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5587	001	0	1	01	01	H5587_001_0	11	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	2	Brand	1	Brand	25	25								25		25	25								25	Brand																								
H5587	001	0	1	01	01	H5587_001_0	11	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H5587	002	0	1	01	01	H5587_002_0	11	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5587	002	0	1	01	01	H5587_002_0	11	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	2	Brand	1	Brand	25	25								25		25	25								25	Brand																								
H5587	002	0	1	01	01	H5587_002_0	11	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H5590	001	0	1	01	01	H5590_001_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	30	90									29		90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	95.00									95.00		95.00								95.00			
H5590	001	0	1	01	01	H5590_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	45.00									45.00		45.00								45.00			
H5590	001	0	1	01	01	H5590_001_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	2	Generic																						Generic	0.00	0.00									0.00		0.00								0.00			
H5590	001	0	1	01	01	H5590_001_0	7	4	4	1	Injectables	000001	1	2	1	Injectables	111000000001010000000	30	90									29		90								31	2	Injectables	2	Injectables																						Injectables	95.00	95.00									95.00		95.00								95.00			
H5590	002	0	1	01	01	H5590_002_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	2	Generic																						Generic	0.00	0.00									0.00		0.00								0.00			
H5590	002	0	1	01	01	H5590_002_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	45.00									45.00		45.00								45.00			
H5590	002	0	1	01	01	H5590_002_0	7	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	30	90									29		90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	95.00									95.00		95.00								95.00			
H5590	002	0	1	01	01	H5590_002_0	7	4	4	1	Injectables	000001	1	2	1	Injectables	111000000001010000000	30	90									29		90								31	2	Injectables	2	Injectables																						Injectables	95.00	95.00									95.00		95.00								95.00			
H5591	001	0	1	02	01	H5591_001_0	3	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010111000000	30	90								30		30	90	60							31	1	Tier 3	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	3	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5591	001	0	1	02	01	H5591_001_0	3	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5591	001	0	1	02	01	H5591_001_0	3	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H5591	001	0	1	02	01	H5591_001_0	3	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010111000000	30	90								30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00	1	1	
H5591	001	0	1	02	01	H5591_001_0	3	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010111000000	30	90								30		30	90	60							31	1	Tier 4	1	Tier 4	25	25								25		25	25	25							25	Tier 4																								
H5591	001	0	1	02	01	H5591_001_0	3	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010111000000	30	90								30		30	90	60							31	1	Tier 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	3	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010111000000	30	90								30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00		5.00	12.50	10.00							5.00			
H5594	001	0	1	01	01	H5594_001_0	6	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5594	001	0	1	01	01	H5594_001_0	6	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H5594	001	0	1	01	01	H5594_001_0	6	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H5594	001	0	1	01	01	H5594_001_0	6	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5594	001	0	1	01	01	H5594_001_0	6	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5594	001	0	1	01	01	H5594_001_0	6	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5594	001	0	1	01	01	H5594_001_0	6	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5594	001	0	1	01	01	H5594_001_0	6	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5594	002	0	1	01	01	H5594_002_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00		60.00	120.00								60.00			
H5594	002	0	1	01	01	H5594_002_0	5	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5594	002	0	1	01	01	H5594_002_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5594	002	0	1	01	01	H5594_002_0	5	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5594	002	0	1	01	01	H5594_002_0	5	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5594	002	0	1	01	01	H5594_002_0	5	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5594	002	0	1	01	01	H5594_002_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5594	002	0	1	01	01	H5594_002_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	20.00	60.00								20.00		20.00	40.00								20.00			
H5594	006	0	1	01	01	H5594_006_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5594	006	0	1	01	01	H5594_006_0	4	3	4	3	Tier 3	010100	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5594	006	0	1	01	01	H5594_006_0	4	2	4	3	Tier2	010001	3	2	2	Tier2																								Tier2		Tier2																						Tier2																						2		
H5594	006	0	1	01	01	H5594_006_0	4	1	4	3	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5594	006	0	1	01	01	H5594_006_0	4	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5594	006	0	1	01	01	H5594_006_0	4	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H5594	006	0	1	01	01	H5594_006_0	4	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H5594	006	0	1	01	01	H5594_006_0	4	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5594	018	0	1	01	01	H5594_018_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H5594	018	0	1	01	01	H5594_018_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H5594	018	0	1	01	01	H5594_018_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5594	018	0	1	01	01	H5594_018_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5594	019	0	1	01	01	H5594_019_0	4	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H5594	019	0	1	01	01	H5594_019_0	4	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H5594	019	0	1	01	01	H5594_019_0	4	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H5594	019	0	1	01	01	H5594_019_0	4	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H5608	002	0	1	01	01	H5608_002_0	5	2	4	1	Tier II	000001	1	2	1	Tier II	111000000001110000000	31	90									10	31	90								31	1	Tier II	2	Tier II																						Tier II	35.00	105.00									35.00	35.00	105.00								35.00			
H5608	002	0	1	01	01	H5608_002_0	5	1	4	1	Tier I	010000	1	2	2	Tier I	111000000001110000000	31	90									10	31	90								31	1	Tier I	2	Tier I																						Tier I	7.00	21.00									7.00	7.00	21.00								7.00			
H5608	002	0	1	01	01	H5608_002_0	5	3	4	1	Tier III	100000	1	1	2	Tier III	111000000001110000000	31	90									10	31	90								31	1	Tier III	2	Tier III																						Tier III	50.00	150.00									50.00	50.00	150.00								50.00			
H5609	001	0	1	01	01	H5609_001_0	7	4	4	1	Non-preferred Brand	100000	1	2	1	Non-preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-preferred Brand	2	Non-preferred Brand																						Non-preferred Brand	60.00	180.00								60.00			120.00								60.00			
H5609	001	0	1	01	01	H5609_001_0	7	6	4	3	Specialty	110010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5609	001	0	1	01	01	H5609_001_0	7	6	4	1	Specialty	110010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H5609	001	0	1	01	01	H5609_001_0	7	1	4	3	Preferred Generics	001000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	2	Preferred Generics	2	Preferred Generics																						Preferred Generics	4.00	12.00								4.00			8.00								4.00	1	1	
H5609	001	0	1	01	01	H5609_001_0	7	2	4	3	Non-Preferred Generics	000100	1	2	2	Non-Preferred Generics																								Non-Preferred Generics		Non-Preferred Generics																						Non-Preferred Generics																						2		
H5609	001	0	1	01	01	H5609_001_0	7	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5609	001	0	1	01	01	H5609_001_0	7	4	4	3	Non-preferred Brand	100000	1	2	1	Non-preferred Brand																								Non-preferred Brand		Non-preferred Brand																						Non-preferred Brand																						2		
H5609	001	0	1	01	01	H5609_001_0	7	5	4	3	Injectables	010000	1	2	2	Injectables																								Injectables		Injectables																						Injectables																						2		
H5609	001	0	1	01	01	H5609_001_0	7	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			60.00								30.00			
H5609	001	0	1	01	01	H5609_001_0	7	2	4	1	Non-Preferred Generics	000100	1	2	2	Non-Preferred Generics	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generics	2	Non-Preferred Generics																						Non-Preferred Generics	12.00	36.00								12.00			24.00								12.00			
H5609	001	0	1	01	01	H5609_001_0	7	1	4	1	Preferred Generics	001000	1	2	2	Preferred Generics	111000000010010000000	30	90								30			90								31	2	Preferred Generics	2	Preferred Generics																						Preferred Generics	4.00	12.00								4.00			8.00								4.00			
H5609	001	0	1	01	01	H5609_001_0	7	5	4	1	Injectables	010000	1	2	2	Injectables	111000000010010000000	30	90								30			90								31	2	Injectables	1	Injectables	33	33								33			33								33	Injectables																								
H5619	001	0	1	01	01	H5619_001_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5619	001	0	1	01	01	H5619_001_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5619	001	0	1	01	01	H5619_001_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5619	001	0	1	01	01	H5619_001_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5619	001	0	1	01	01	H5619_001_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5619	001	0	1	01	01	H5619_001_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5619	001	0	1	01	01	H5619_001_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5619	001	0	1	01	01	H5619_001_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																						2		
H5619	001	0	1	01	01	H5619_001_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5619	001	0	1	01	01	H5619_001_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5619	004	0	1	01	01	H5619_004_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5619	004	0	1	01	01	H5619_004_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5619	004	0	1	01	01	H5619_004_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																						2		
H5619	004	0	1	01	01	H5619_004_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5619	004	0	1	01	01	H5619_004_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5619	004	0	1	01	01	H5619_004_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5619	004	0	1	01	01	H5619_004_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5619	004	0	1	01	01	H5619_004_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5619	004	0	1	01	01	H5619_004_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5619	004	0	1	01	01	H5619_004_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5619	007	0	1	01	01	H5619_007_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5619	007	0	1	01	01	H5619_007_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5619	007	0	1	01	01	H5619_007_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5619	007	0	1	01	01	H5619_007_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5619	007	0	1	01	01	H5619_007_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5619	007	0	1	01	01	H5619_007_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5619	007	0	1	01	01	H5619_007_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																						2		
H5619	007	0	1	01	01	H5619_007_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5619	007	0	1	01	01	H5619_007_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5619	007	0	1	01	01	H5619_007_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5619	008	0	1	01	01	H5619_008_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5619	008	0	1	01	01	H5619_008_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5619	008	0	1	01	01	H5619_008_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																						2		
H5619	008	0	1	01	01	H5619_008_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5619	008	0	1	01	01	H5619_008_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5619	008	0	1	01	01	H5619_008_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5619	008	0	1	01	01	H5619_008_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5619	008	0	1	01	01	H5619_008_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5619	008	0	1	01	01	H5619_008_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5619	008	0	1	01	01	H5619_008_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5628	001	0	1	01	01	H5628_001_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H5628	001	0	1	01	01	H5628_001_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5628	001	0	1	01	01	H5628_001_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5628	001	0	1	01	01	H5628_001_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5628	002	0	1	01	01	H5628_002_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H5628	002	0	1	01	01	H5628_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	55.00	165.00								55.00			165.00								55.00			
H5628	002	0	1	01	01	H5628_002_0	6	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H5628	002	0	1	01	01	H5628_002_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H5628	006	0	1	01	01	H5628_006_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5628	006	0	1	01	01	H5628_006_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5628	006	0	1	01	01	H5628_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H5628	006	0	1	01	01	H5628_006_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5640	001	0	1	01	01	H5640_001_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5640	001	0	1	01	01	H5640_001_0	2	2	4	1	Brand	000001	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	2	Brand	1	Brand	25	25								25		25	25								25	Brand																								
H5640	001	0	1	01	01	H5640_001_0	2	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5640	001	0	1	01	01	H5640_001_0	2	2	4	3	Brand	000001	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H5649	001	0	1	01	01	H5649_001_0	5	1	4	1	Generic	011100	3	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5649	001	0	1	01	01	H5649_001_0	5	2	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00		20.00	60.00								20.00			
H5649	001	0	1	01	01	H5649_001_0	5	3	4	1	Brand	100010	3	2	2	Brand	111000000010110000000	30	90								30		30	90								31	1	Brand	2	Brand																						Brand	40.00	120.00								40.00		40.00	120.00								40.00			
H5649	001	0	1	01	01	H5649_001_0	5	4	4	1	Specialty Drugs	111111	1	1	1	Specialty Drugs	111000000010110000000	30	90								30		30	90								31	2	Specialty Drugs	1	Specialty Drugs	33	33								33		33	33								33	Specialty Drugs																								
H5652	001	0	1	37	05	H5652_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5652	001	0	1	37	05	H5652_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5652	001	0	1	37	05	H5652_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5652	001	0	1	37	05	H5652_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5652	003	0	1	37	05	H5652_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5652	003	0	1	37	05	H5652_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5652	003	0	1	37	05	H5652_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5652	003	0	1	37	05	H5652_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5652	004	0	1	37	05	H5652_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5652	004	0	1	37	05	H5652_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5652	004	0	1	37	05	H5652_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5652	004	0	1	37	05	H5652_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5656	001	0	1	01	01	H5656_001_0	9	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5656	001	0	1	01	01	H5656_001_0	9	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5656	001	0	1	01	01	H5656_001_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00	1	1	
H5656	001	0	1	01	01	H5656_001_0	9	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5656	001	0	1	01	01	H5656_001_0	9	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H5656	001	0	1	01	01	H5656_001_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H5656	001	0	1	01	01	H5656_001_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H5656	001	0	1	01	01	H5656_001_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00	1	2	10000000
H5656	009	0	1	01	01	H5656_009_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H5656	009	0	1	01	01	H5656_009_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H5656	009	0	1	01	01	H5656_009_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H5656	009	0	1	01	01	H5656_009_0	6	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H5656	009	0	1	01	01	H5656_009_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00	1	1	
H5656	009	0	1	01	01	H5656_009_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00	1	2	10000000
H5656	009	0	1	01	01	H5656_009_0	6	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5656	009	0	1	01	01	H5656_009_0	6	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5665	002	0	1	01	01	H5665_002_0	5	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	37.00	111.00								37.00		37.00	93.00								37.00			
H5665	002	0	1	01	01	H5665_002_0	5	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	23.00								9.00			
H5665	002	0	1	01	01	H5665_002_0	5	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	30	30								30		30	30								30	Formulary Specialty																								
H5665	002	0	1	01	01	H5665_002_0	5	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	238.00								95.00			
H5678	001	0	1	37	05	H5678_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5678	001	0	1	37	05	H5678_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5678	001	0	1	37	05	H5678_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5678	001	0	1	37	05	H5678_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5678	003	0	1	37	05	H5678_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5678	003	0	1	37	05	H5678_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5678	003	0	1	37	05	H5678_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5678	003	0	1	37	05	H5678_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5678	004	0	1	37	05	H5678_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5678	004	0	1	37	05	H5678_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5678	004	0	1	37	05	H5678_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5678	004	0	1	37	05	H5678_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5679	001	0	1	01	01	H5679_001_0	7	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5679	001	0	1	01	01	H5679_001_0	7	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5679	001	0	1	01	01	H5679_001_0	7	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5679	001	0	1	01	01	H5679_001_0	7	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5679	001	0	1	01	01	H5679_001_0	7	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5679	001	0	1	01	01	H5679_001_0	7	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5679	001	0	1	01	01	H5679_001_0	7	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5679	001	0	1	01	01	H5679_001_0	7	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5679	001	0	1	01	01	H5679_001_0	7	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5679	001	0	1	01	01	H5679_001_0	7	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5679	002	0	1	01	01	H5679_002_0	7	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5679	002	0	1	01	01	H5679_002_0	7	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5679	002	0	1	01	01	H5679_002_0	7	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5679	002	0	1	01	01	H5679_002_0	7	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5679	002	0	1	01	01	H5679_002_0	7	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5679	002	0	1	01	01	H5679_002_0	7	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5679	002	0	1	01	01	H5679_002_0	7	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5679	002	0	1	01	01	H5679_002_0	7	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H5679	002	0	1	01	01	H5679_002_0	7	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
H5679	002	0	1	01	01	H5679_002_0	7	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5685	001	0	1	01	01	H5685_001_0	2	2	4	1	Brand	000010	1	2	1	Brand	110000000001000000000	30										29										31		Brand	2	Brand																						Brand	0.00										0.00										0.00			
H5685	001	0	1	01	01	H5685_001_0	2	1	4	1	Generic	010000	1	2	2	Generic	110000000001000000000	30										29										31		Generic	2	Generic																						Generic	0.00										0.00										0.00			
H5696	001	0	1	01	01	H5696_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	001	0	1	01	01	H5696_001_0	7	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00			15.00								5.00			
H5696	001	0	1	01	01	H5696_001_0	7	5	4	3	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty																								Tier 5 - Injectables  Specialty		Tier 5 - Injectables  Specialty																						Tier 5 - Injectables  Specialty																						2		
H5696	001	0	1	01	01	H5696_001_0	7	4	4	3	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred																								Tier 4 - Non-Preferred		Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred																						2		
H5696	001	0	1	01	01	H5696_001_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																						2		
H5696	001	0	1	01	01	H5696_001_0	7	2	4	3	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic																								Tier 2 - Generic		Tier 2 - Generic																						Tier 2 - Generic																						2		
H5696	001	0	1	01	01	H5696_001_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00								30.00			80.00								30.00			
H5696	001	0	1	01	01	H5696_001_0	7	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	80.00	240.00								80.00			240.00								80.00			
H5696	001	0	1	01	01	H5696_001_0	7	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	001	0	1	01	01	H5696_001_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	002	0	1	01	01	H5696_002_0	5	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	90.00	270.00								90.00			270.00								90.00			
H5696	002	0	1	01	01	H5696_002_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00								40.00			110.00								40.00			
H5696	002	0	1	01	01	H5696_002_0	5	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	10.00	30.00								10.00			30.00								10.00			
H5696	002	0	1	01	01	H5696_002_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			5.00								5.00			
H5696	002	0	1	01	01	H5696_002_0	5	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	003	0	1	01	01	H5696_003_0	6	5	4	3	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty																								Tier 5 - Injectables  Specialty		Tier 5 - Injectables  Specialty																						Tier 5 - Injectables  Specialty																						2		
H5696	003	0	1	01	01	H5696_003_0	6	4	4	3	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred																								Tier 4 - Non-Preferred		Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred																						2		
H5696	003	0	1	01	01	H5696_003_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																						2		
H5696	003	0	1	01	01	H5696_003_0	6	2	4	3	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic																								Tier 2 - Generic		Tier 2 - Generic																						Tier 2 - Generic																						2		
H5696	003	0	1	01	01	H5696_003_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	003	0	1	01	01	H5696_003_0	6	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	003	0	1	01	01	H5696_003_0	6	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	80.00	240.00								80.00			240.00								80.00			
H5696	003	0	1	01	01	H5696_003_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00			95.00								35.00			
H5696	003	0	1	01	01	H5696_003_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	003	0	1	01	01	H5696_003_0	6	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00			
H5696	004	0	1	01	01	H5696_004_0	6	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	90.00	270.00								90.00			270.00								90.00			
H5696	004	0	1	01	01	H5696_004_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00								40.00			110.00								40.00			
H5696	004	0	1	01	01	H5696_004_0	6	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	5.00	15.00								5.00			15.00								5.00			
H5696	004	0	1	01	01	H5696_004_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	004	0	1	01	01	H5696_004_0	6	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	023	0	1	01	01	H5696_023_0	5	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	80.00	240.00								80.00			240.00								80.00			
H5696	023	0	1	01	01	H5696_023_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00								30.00			80.00								30.00			
H5696	023	0	1	01	01	H5696_023_0	5	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	10.00	30.00								10.00			30.00								10.00			
H5696	023	0	1	01	01	H5696_023_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	023	0	1	01	01	H5696_023_0	5	5	4	3	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty																								Tier 5 - Injectables  Specialty		Tier 5 - Injectables  Specialty																						Tier 5 - Injectables  Specialty																						2		
H5696	023	0	1	01	01	H5696_023_0	5	4	4	3	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred																								Tier 4 - Non-Preferred		Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred																						2		
H5696	023	0	1	01	01	H5696_023_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																						2		
H5696	023	0	1	01	01	H5696_023_0	5	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	023	0	1	01	01	H5696_023_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	023	0	1	01	01	H5696_023_0	5	2	4	3	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic																								Tier 2 - Generic		Tier 2 - Generic																						Tier 2 - Generic																						2		
H5696	024	0	1	01	01	H5696_024_0	6	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	90.00	270.00								90.00			270.00								90.00			
H5696	024	0	1	01	01	H5696_024_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	45.00	135.00								45.00			125.00								45.00			
H5696	024	0	1	01	01	H5696_024_0	6	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	10.00	30.00								10.00			30.00								10.00			
H5696	024	0	1	01	01	H5696_024_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	10.00								5.00			5.00								5.00			
H5696	024	0	1	01	01	H5696_024_0	6	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	025	0	1	01	01	H5696_025_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	025	0	1	01	01	H5696_025_0	5	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00			
H5696	025	0	1	01	01	H5696_025_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00								30.00			80.00								30.00			
H5696	025	0	1	01	01	H5696_025_0	5	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	80.00	240.00								80.00			240.00								80.00			
H5696	025	0	1	01	01	H5696_025_0	5	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	025	0	1	01	01	H5696_025_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	025	0	1	01	01	H5696_025_0	5	2	4	3	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	025	0	1	01	01	H5696_025_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																						2		
H5696	025	0	1	01	01	H5696_025_0	5	4	4	3	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred																								Tier 4 - Non-Preferred		Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred																						2		
H5696	025	0	1	01	01	H5696_025_0	5	5	4	3	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty																								Tier 5 - Injectables  Specialty		Tier 5 - Injectables  Specialty																						Tier 5 - Injectables  Specialty																						2		
H5696	026	0	1	01	01	H5696_026_0	6	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	90.00	270.00								90.00			270.00								90.00			
H5696	026	0	1	01	01	H5696_026_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00								40.00			110.00								40.00			
H5696	026	0	1	01	01	H5696_026_0	6	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00			
H5696	026	0	1	01	01	H5696_026_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	026	0	1	01	01	H5696_026_0	6	5	4	3	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty																								Tier 5 - Injectables  Specialty		Tier 5 - Injectables  Specialty																						Tier 5 - Injectables  Specialty																						2		
H5696	026	0	1	01	01	H5696_026_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	026	0	1	01	01	H5696_026_0	6	2	4	3	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	026	0	1	01	01	H5696_026_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																						2		
H5696	026	0	1	01	01	H5696_026_0	6	4	4	3	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred																								Tier 4 - Non-Preferred		Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred																						2		
H5696	026	0	1	01	01	H5696_026_0	6	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	027	0	1	01	01	H5696_027_0	7	5	4	3	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty																								Tier 5 - Injectables  Specialty		Tier 5 - Injectables  Specialty																						Tier 5 - Injectables  Specialty																						2		
H5696	027	0	1	01	01	H5696_027_0	7	4	4	3	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred																								Tier 4 - Non-Preferred		Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred																						2		
H5696	027	0	1	01	01	H5696_027_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																						2		
H5696	027	0	1	01	01	H5696_027_0	7	2	4	3	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	027	0	1	01	01	H5696_027_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5696	027	0	1	01	01	H5696_027_0	7	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5696	027	0	1	01	01	H5696_027_0	7	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	80.00	240.00								80.00			240.00								80.00			
H5696	027	0	1	01	01	H5696_027_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00								30.00			80.00								30.00			
H5696	027	0	1	01	01	H5696_027_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	027	0	1	01	01	H5696_027_0	7	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00			
H5696	028	0	1	01	01	H5696_028_0	6	4	4	1	Tier 4 - Non-Preferred	100100	1	2	1	Tier 4 - Non-Preferred	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred	2	Tier 4 - Non-Preferred																						Tier 4 - Non-Preferred	90.00	270.00								90.00			270.00								90.00			
H5696	028	0	1	01	01	H5696_028_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	40.00	120.00								40.00			110.00								40.00			
H5696	028	0	1	01	01	H5696_028_0	6	2	4	1	Tier 2 - Generic	010000	1	2	2	Tier 2 - Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Generic	2	Tier 2 - Generic																						Tier 2 - Generic	0.00	0.00								0.00			0.00								0.00			
H5696	028	0	1	01	01	H5696_028_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5696	028	0	1	01	01	H5696_028_0	6	5	4	1	Tier 5 - Injectables  Specialty	010010	1	1	2	Tier 5 - Injectables  Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Injectables  Specialty	1	Tier 5 - Injectables  Specialty	33	33								33			33								33	Tier 5 - Injectables  Specialty																								
H5697	001	0	1	37	05	H5697_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5697	001	0	1	37	05	H5697_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5697	001	0	1	37	05	H5697_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5697	001	0	1	37	05	H5697_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5697	003	0	1	37	05	H5697_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5697	003	0	1	37	05	H5697_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5697	003	0	1	37	05	H5697_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5697	003	0	1	37	05	H5697_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5697	004	0	1	37	05	H5697_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5697	004	0	1	37	05	H5697_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5697	004	0	1	37	05	H5697_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5697	004	0	1	37	05	H5697_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5698	020	0	1	01	01	H5698_020_0	6	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	020	0	1	01	01	H5698_020_0	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	020	0	1	01	01	H5698_020_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	020	0	1	01	01	H5698_020_0	6	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
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																						2		
H5698	020	0	1	01	01	H5698_020_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	020	0	1	01	01	H5698_020_0	6	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	020	0	1	01	01	H5698_020_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	020	0	1	01	01	H5698_020_0	6	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	020	0	1	01	01	H5698_020_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	6	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	028	0	1	01	01	H5698_028_0	6	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	028	0	1	01	01	H5698_028_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																						2		
H5698	028	0	1	01	01	H5698_028_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	028	0	1	01	01	H5698_028_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	028	0	1	01	01	H5698_028_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	028	0	1	01	01	H5698_028_0	6	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	028	0	1	01	01	H5698_028_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	028	0	1	01	01	H5698_028_0	6	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	036	0	1	01	01	H5698_036_0	5	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	036	0	1	01	01	H5698_036_0	5	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	036	0	1	01	01	H5698_036_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	5	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	036	0	1	01	01	H5698_036_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	036	0	1	01	01	H5698_036_0	5	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	036	0	1	01	01	H5698_036_0	5	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	036	0	1	01	01	H5698_036_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																						2		
H5698	036	0	1	01	01	H5698_036_0	5	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	036	0	1	01	01	H5698_036_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	061	0	1	01	01	H5698_061_0	4	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	061	0	1	01	01	H5698_061_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																						2		
H5698	061	0	1	01	01	H5698_061_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	061	0	1	01	01	H5698_061_0	4	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	061	0	1	01	01	H5698_061_0	4	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	061	0	1	01	01	H5698_061_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	4	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	061	0	1	01	01	H5698_061_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	061	0	1	01	01	H5698_061_0	4	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	061	0	1	01	01	H5698_061_0	4	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	062	0	1	01	01	H5698_062_0	4	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	062	0	1	01	01	H5698_062_0	4	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	062	0	1	01	01	H5698_062_0	4	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	062	0	1	01	01	H5698_062_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	062	0	1	01	01	H5698_062_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	062	0	1	01	01	H5698_062_0	4	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	062	0	1	01	01	H5698_062_0	4	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	062	0	1	01	01	H5698_062_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																						2		
H5698	062	0	1	01	01	H5698_062_0	4	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	063	0	1	01	01	H5698_063_0	5	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
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																						2		
H5698	063	0	1	01	01	H5698_063_0	5	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	063	0	1	01	01	H5698_063_0	5	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	063	0	1	01	01	H5698_063_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	063	0	1	01	01	H5698_063_0	5	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	063	0	1	01	01	H5698_063_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	063	0	1	01	01	H5698_063_0	5	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	063	0	1	01	01	H5698_063_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	067	0	1	01	01	H5698_067_0	5	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
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																						2		
H5698	067	0	1	01	01	H5698_067_0	5	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	067	0	1	01	01	H5698_067_0	5	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	067	0	1	01	01	H5698_067_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	067	0	1	01	01	H5698_067_0	5	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	067	0	1	01	01	H5698_067_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	067	0	1	01	01	H5698_067_0	5	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	067	0	1	01	01	H5698_067_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	068	0	1	01	01	H5698_068_0	4	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
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																						2		
H5698	068	0	1	01	01	H5698_068_0	4	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	068	0	1	01	01	H5698_068_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	068	0	1	01	01	H5698_068_0	4	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	068	0	1	01	01	H5698_068_0	4	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	068	0	1	01	01	H5698_068_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	068	0	1	01	01	H5698_068_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	068	0	1	01	01	H5698_068_0	4	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	069	0	1	01	01	H5698_069_0	5	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	069	0	1	01	01	H5698_069_0	5	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	069	0	1	01	01	H5698_069_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	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	5	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	069	0	1	01	01	H5698_069_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	069	0	1	01	01	H5698_069_0	5	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	069	0	1	01	01	H5698_069_0	5	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	069	0	1	01	01	H5698_069_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																						2		
H5698	069	0	1	01	01	H5698_069_0	5	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	069	0	1	01	01	H5698_069_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	123	0	1	01	01	H5698_123_0	7	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	123	0	1	01	01	H5698_123_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	123	0	1	01	01	H5698_123_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																						2		
H5698	123	0	1	01	01	H5698_123_0	7	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	123	0	1	01	01	H5698_123_0	7	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	123	0	1	01	01	H5698_123_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	123	0	1	01	01	H5698_123_0	7	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	123	0	1	01	01	H5698_123_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	123	0	1	01	01	H5698_123_0	7	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	123	0	1	01	01	H5698_123_0	7	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	129	0	1	01	01	H5698_129_0	5	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	129	0	1	01	01	H5698_129_0	5	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	129	0	1	01	01	H5698_129_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																						2		
H5698	129	0	1	01	01	H5698_129_0	5	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	129	0	1	01	01	H5698_129_0	5	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	129	0	1	01	01	H5698_129_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	129	0	1	01	01	H5698_129_0	5	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	129	0	1	01	01	H5698_129_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	129	0	1	01	01	H5698_129_0	5	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	129	0	1	01	01	H5698_129_0	5	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	135	0	1	01	01	H5698_135_0	4	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	135	0	1	01	01	H5698_135_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	135	0	1	01	01	H5698_135_0	4	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	135	0	1	01	01	H5698_135_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	135	0	1	01	01	H5698_135_0	4	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	135	0	1	01	01	H5698_135_0	4	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	135	0	1	01	01	H5698_135_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																						2		
H5698	135	0	1	01	01	H5698_135_0	4	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	135	0	1	01	01	H5698_135_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	135	0	1	01	01	H5698_135_0	4	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	141	0	1	01	01	H5698_141_0	4	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	141	0	1	01	01	H5698_141_0	4	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	141	0	1	01	01	H5698_141_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	141	0	1	01	01	H5698_141_0	4	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	141	0	1	01	01	H5698_141_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	141	0	1	01	01	H5698_141_0	4	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	141	0	1	01	01	H5698_141_0	4	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	141	0	1	01	01	H5698_141_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																						2		
H5698	141	0	1	01	01	H5698_141_0	4	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	141	0	1	01	01	H5698_141_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	150	0	1	01	01	H5698_150_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	150	0	1	01	01	H5698_150_0	6	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	150	0	1	01	01	H5698_150_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	150	0	1	01	01	H5698_150_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																						2		
H5698	150	0	1	01	01	H5698_150_0	6	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	150	0	1	01	01	H5698_150_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	150	0	1	01	01	H5698_150_0	6	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	150	0	1	01	01	H5698_150_0	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	150	0	1	01	01	H5698_150_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00			
H5698	150	0	1	01	01	H5698_150_0	6	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	151	0	1	01	01	H5698_151_0	7	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	151	0	1	01	01	H5698_151_0	7	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	151	0	1	01	01	H5698_151_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00			
H5698	151	0	1	01	01	H5698_151_0	7	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	151	0	1	01	01	H5698_151_0	7	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	151	0	1	01	01	H5698_151_0	7	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	151	0	1	01	01	H5698_151_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																						2		
H5698	151	0	1	01	01	H5698_151_0	7	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	151	0	1	01	01	H5698_151_0	7	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	151	0	1	01	01	H5698_151_0	7	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	152	0	1	01	01	H5698_152_0	6	4	4	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - NonPreferred Brand/NonPreferred Generic	2	Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic	60.00	180.00								60.00		60.00	180.00								60.00			
H5698	152	0	1	01	01	H5698_152_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	152	0	1	01	01	H5698_152_0	6	1	4	3	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	152	0	1	01	01	H5698_152_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	152	0	1	01	01	H5698_152_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																						2		
H5698	152	0	1	01	01	H5698_152_0	6	4	4	3	Tier 4 - NonPreferred Brand/NonPreferred Generic	101100	1	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic																								Tier 4 - NonPreferred Brand/NonPreferred Generic		Tier 4 - NonPreferred Brand/NonPreferred Generic																						Tier 4 - NonPreferred Brand/NonPreferred Generic																						2		
H5698	152	0	1	01	01	H5698_152_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	152	0	1	01	01	H5698_152_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00		35.00	105.00								35.00			
H5698	152	0	1	01	01	H5698_152_0	6	1	4	1	Tier 1- Preferred Generic	001000	1	2	2	Tier 1- Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic	2	Tier 1- Preferred Generic																						Tier 1- Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	152	0	1	01	01	H5698_152_0	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	153	0	1	01	01	H5698_153_0	8	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	153	0	1	01	01	H5698_153_0	8	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	153	0	1	01	01	H5698_153_0	8	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	153	0	1	01	01	H5698_153_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																						2		
H5698	153	0	1	01	01	H5698_153_0	8	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	153	0	1	01	01	H5698_153_0	8	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	153	0	1	01	01	H5698_153_0	8	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	153	0	1	01	01	H5698_153_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	153	0	1	01	01	H5698_153_0	8	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	153	0	1	01	01	H5698_153_0	8	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	154	0	1	01	01	H5698_154_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	154	0	1	01	01	H5698_154_0	6	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	154	0	1	01	01	H5698_154_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	154	0	1	01	01	H5698_154_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	154	0	1	01	01	H5698_154_0	6	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	154	0	1	01	01	H5698_154_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																						2		
H5698	154	0	1	01	01	H5698_154_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	154	0	1	01	01	H5698_154_0	6	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	154	0	1	01	01	H5698_154_0	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	154	0	1	01	01	H5698_154_0	6	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	155	0	1	01	01	H5698_155_0	6	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	155	0	1	01	01	H5698_155_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	155	0	1	01	01	H5698_155_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																						2		
H5698	155	0	1	01	01	H5698_155_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	155	0	1	01	01	H5698_155_0	6	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5698	155	0	1	01	01	H5698_155_0	6	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	155	0	1	01	01	H5698_155_0	6	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	155	0	1	01	01	H5698_155_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	155	0	1	01	01	H5698_155_0	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	155	0	1	01	01	H5698_155_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	156	0	1	01	01	H5698_156_0	6	4	4	3	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	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																						2		
H5698	156	0	1	01	01	H5698_156_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																						2		
H5698	156	0	1	01	01	H5698_156_0	6	2	4	3	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand																								Tier 2 - Generic or Brand		Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand																						2		
H5698	156	0	1	01	01	H5698_156_0	6	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5698	156	0	1	01	01	H5698_156_0	6	2	4	1	Tier 2 - Generic or Brand	010010	1	2	2	Tier 2 - Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 2 - Generic or Brand	2	Tier 2 - Generic or Brand																						Tier 2 - Generic or Brand	10.00	30.00								10.00		10.00	30.00								10.00			
H5698	156	0	1	01	01	H5698_156_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00								25.00		25.00	75.00								25.00			
H5698	156	0	1	01	01	H5698_156_0	6	4	4	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	100100	1	2	1	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic	2	Tier 4 - Non-Preferred Brand/Non-Preferred Generic																						Tier 4 - Non-Preferred Brand/Non-Preferred Generic	45.00	135.00								45.00		45.00	135.00								45.00			
H5698	156	0	1	01	01	H5698_156_0	6	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000010110000000	30	90								30		30	90								31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33								33		33	33								33	Tier 5 - Specialty																								
H5698	156	0	1	01	01	H5698_156_0	6	1	4	3	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00	1	1	
H5698	156	0	1	01	01	H5698_156_0	6	1	4	1	Tier 1- Preferred Generic or Brand	001010	1	2	2	Tier 1- Preferred Generic or Brand	111000000010110000000	30	90								30		30	90								31	2	Tier 1- Preferred Generic or Brand	2	Tier 1- Preferred Generic or Brand																						Tier 1- Preferred Generic or Brand	5.00	15.00								5.00		5.00	15.00								5.00			
H5700	002	0	1	01	01	H5700_002_0	9	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5700	002	0	1	01	01	H5700_002_0	9	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5700	002	0	1	01	01	H5700_002_0	9	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5700	002	0	1	01	01	H5700_002_0	9	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5700	002	0	1	01	01	H5700_002_0	9	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5700	002	0	1	01	01	H5700_002_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5700	002	0	1	01	01	H5700_002_0	9	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00			
H5700	002	0	1	01	01	H5700_002_0	9	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5700	002	0	1	01	01	H5700_002_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5700	002	0	1	01	01	H5700_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																						2		
H5700	005	0	1	01	01	H5700_005_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5700	005	0	1	01	01	H5700_005_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5700	005	0	1	01	01	H5700_005_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5700	005	0	1	01	01	H5700_005_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																						2		
H5700	005	0	1	01	01	H5700_005_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1																																																																							2		
H5700	005	0	1	01	01	H5700_005_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H5700	005	0	1	01	01	H5700_005_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5700	005	0	1	01	01	H5700_005_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5700	005	0	1	01	01	H5700_005_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5700	005	0	1	01	01	H5700_005_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5700	009	0	1	01	01	H5700_009_0	9	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5700	009	0	1	01	01	H5700_009_0	9	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5700	009	0	1	01	01	H5700_009_0	9	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5700	009	0	1	01	01	H5700_009_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																						2		
H5700	009	0	1	01	01	H5700_009_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5700	009	0	1	01	01	H5700_009_0	9	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5700	009	0	1	01	01	H5700_009_0	9	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5700	009	0	1	01	01	H5700_009_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5700	009	0	1	01	01	H5700_009_0	9	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5700	009	0	1	01	01	H5700_009_0	9	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00			
H5700	020	0	1	01	01	H5700_020_0	9	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5700	020	0	1	01	01	H5700_020_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5700	020	0	1	01	01	H5700_020_0	9	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5700	020	0	1	01	01	H5700_020_0	9	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5700	020	0	1	01	01	H5700_020_0	9	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5700	020	0	1	01	01	H5700_020_0	9	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5700	020	0	1	01	01	H5700_020_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5700	020	0	1	01	01	H5700_020_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																						2		
H5700	020	0	1	01	01	H5700_020_0	9	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5700	020	0	1	01	01	H5700_020_0	9	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	5.00	15.00								5.00			10.00								5.00			
H5700	025	0	1	02	01	H5700_025_0	9	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	5.00	15.00								5.00			10.00								5.00			
H5700	025	0	1	02	01	H5700_025_0	9	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5700	025	0	1	02	01	H5700_025_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																						2		
H5700	025	0	1	02	01	H5700_025_0	9	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5700	025	0	1	02	01	H5700_025_0	9	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5700	025	0	1	02	01	H5700_025_0	9	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5700	025	0	1	02	01	H5700_025_0	9	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5700	025	0	1	02	01	H5700_025_0	9	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5700	025	0	1	02	01	H5700_025_0	9	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5700	025	0	1	02	01	H5700_025_0	9	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5700	027	0	1	01	01	H5700_027_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5700	027	0	1	01	01	H5700_027_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2																																																																							2		
H5700	027	0	1	01	01	H5700_027_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																						2		
H5700	027	0	1	01	01	H5700_027_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5700	027	0	1	01	01	H5700_027_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5700	027	0	1	01	01	H5700_027_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5700	027	0	1	01	01	H5700_027_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5700	027	0	1	01	01	H5700_027_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5700	027	0	1	01	01	H5700_027_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5700	027	0	1	01	01	H5700_027_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5732	001	0	1	01	01	H5732_001_0	3	4	4	1	Tier 4/ Nivel 4	100100	1	2	1	Tier 4/ Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4/ Nivel 4	2	Tier 4/ Nivel 4																						Tier 4/ Nivel 4	35.00	70.00	35.00							35.00			70.00								35.00			
H5732	001	0	1	01	01	H5732_001_0	3	3	4	1	Tier 3/ Nivel 3	000010	3	2	2	Tier 3/ Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3/ Nivel 3	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	3	2	4	1	Tier 2/ Nivel 2	001001	3	2	2	Tier 2/ Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2/ Nivel 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	3	1	4	1	Tier 1/ Nivel 1	010000	3	2	2	Tier 1/ Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/ Nivel 1	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	3	5	4	1	Tier 5/ Nivel 5	010010	1	1	2	Tier 5/ Nivel 5	111100000010010000000	30	90	15							30			90								31	2	Tier 5/ Nivel 5	1	Tier 5/ Nivel 5	25	25	25							25			25								25	Tier 5/ Nivel 5																								
H5732	001	0	1	01	01	H5732_001_0	3	4	4	3	Tier 4/ Nivel 4	100100	1	2	1	Tier 4/ Nivel 4																								Tier 4/ Nivel 4		Tier 4/ Nivel 4																						Tier 4/ Nivel 4																						2		
H5732	001	0	1	01	01	H5732_001_0	3	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																						2		
H5732	001	0	1	01	01	H5732_001_0	3	2	4	3	Tier 2/ Nivel 2	001001	3	2	2	Tier 2/ Nivel 2																								Tier 2/ Nivel 2		Tier 2/ Nivel 2																						Tier 2/ Nivel 2																						2		
H5732	001	0	1	01	01	H5732_001_0	3	1	4	3	Tier 1/ Nivel 1	010000	3	2	2	Tier 1/ Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1/ Nivel 1	2	Tier 1/ Nivel 1																						Tier 1/ Nivel 1	5.00	10.00	5.00							5.00			10.00								5.00	1	1	
H5732	001	0	1	01	01	H5732_001_0	3	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																						2		
H5736	002	0	1	09	04	H5736_002_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5736	002	0	1	09	04	H5736_002_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					136.00			204.00		68.00			
H5736	002	0	1	09	04	H5736_002_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					52.00			78.00		26.00			
H5736	002	0	1	09	04	H5736_002_0	3	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00			
H5736	002	0	1	09	04	H5736_002_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					50.00			75.00		25.00			
H5736	003	0	1	09	04	H5736_003_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H5736	003	0	1	09	04	H5736_003_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5736	003	0	1	09	04	H5736_003_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					68.00			102.00		34.00			
H5736	003	0	1	09	04	H5736_003_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	74.00	222.00									74.00					148.00			222.00		74.00			
H5736	003	0	1	09	04	H5736_003_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5736	025	0	1	09	04	H5736_025_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5736	025	0	1	09	04	H5736_025_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H5736	025	0	1	09	04	H5736_025_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5736	025	0	1	09	04	H5736_025_0	3	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H5736	025	0	1	09	04	H5736_025_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5746	006	0	1	01	01	H5746_006_0	5	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H5746	006	0	1	01	01	H5746_006_0	5	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H5746	006	0	1	01	01	H5746_006_0	5	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H5746	006	0	1	01	01	H5746_006_0	5	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	5	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5746	006	0	1	01	01	H5746_006_0	5	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5746	006	0	1	01	01	H5746_006_0	5	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5746	006	0	1	01	01	H5746_006_0	5	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5746	006	0	1	01	01	H5746_006_0	5	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5746	006	0	1	01	01	H5746_006_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5746	012	0	1	02	01	H5746_012_0	8	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5746	012	0	1	02	01	H5746_012_0	8	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5746	012	0	1	02	01	H5746_012_0	8	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H5746	012	0	1	02	01	H5746_012_0	8	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H5746	012	0	1	02	01	H5746_012_0	8	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	45.00	135.00	90.00							45.00		45.00	90.00	67.50							45.00			
H5746	012	0	1	02	01	H5746_012_0	8	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	5.00	15.00	10.00							5.00		5.00	10.00	7.50							5.00			
H5746	012	0	1	02	01	H5746_012_0	8	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5746	012	0	1	02	01	H5746_012_0	8	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5746	012	0	1	02	01	H5746_012_0	8	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5746	012	0	1	02	01	H5746_012_0	8	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5749	001	0	1	02	01	H5749_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H5749	001	0	1	02	01	H5749_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H5749	001	0	1	02	01	H5749_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
H5749	001	0	1	02	01	H5749_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5750	003	0	1	02	01	H5750_003_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	2	Generic																						Generic	12.00	36.00									12.00		36.00								12.00			
H5750	003	0	1	02	01	H5750_003_0	4	2	4	1	Brand	000010	1	2	2	Brand	111000000001010000000	30	90									29		90								31	2	Brand	2	Brand																						Brand	35.00	105.00									35.00		105.00								35.00			
H5750	003	0	1	02	01	H5750_003_0	4	3	4	1	Specialty	010010	1	1	1	Specialty	111000000001010000000	30	90									29		90								31	2	Specialty	2	Specialty																						Specialty	70.00	210.00									70.00		210.00								70.00			
H5750	003	0	1	02	01	H5750_003_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	2	Generic																						Generic	12.00	36.00									12.00		36.00								12.00	1	1	
H5750	003	0	1	02	01	H5750_003_0	4	2	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5750	003	0	1	02	01	H5750_003_0	4	3	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5754	001	0	1	37	05	H5754_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5754	001	0	1	37	05	H5754_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5754	001	0	1	37	05	H5754_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5754	001	0	1	37	05	H5754_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5754	003	0	1	37	05	H5754_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5754	003	0	1	37	05	H5754_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5754	003	0	1	37	05	H5754_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5754	003	0	1	37	05	H5754_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5754	004	0	1	37	05	H5754_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5754	004	0	1	37	05	H5754_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5754	004	0	1	37	05	H5754_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5754	004	0	1	37	05	H5754_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5774	005	0	1	01	01	H5774_005_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00									0.00	0.00	0.00								0.00			
H5774	005	0	1	01	01	H5774_005_0	4	2	4	1	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	2.00	6.00									2.00	2.00	6.00								2.00			
H5774	005	0	1	01	01	H5774_005_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Preferred Brand	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	4	4	4	1	Non Preferred Brand	100000	1	2	2	Non Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Brand	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	4	5	4	1	Specialty	010010	1	1	1	Specialty	111000000001110000000	30	90									10	30	90								31	1	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H5774	005	0	1	01	01	H5774_005_0	4	4	4	3	Non Preferred Brand	100000	1	2	2	Non Preferred Brand																								Non Preferred Brand		Non Preferred Brand																						Non Preferred Brand																						2		
H5774	005	0	1	01	01	H5774_005_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00									0.00	0.00	0.00								0.00	1	1	
H5774	005	0	1	01	01	H5774_005_0	4	2	4	3	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	2.00	6.00									2.00	2.00	6.00								2.00	1	1	
H5774	005	0	1	01	01	H5774_005_0	4	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5774	005	0	1	01	01	H5774_005_0	4	6	4	3	Part D Excluded Drugs	000010	2	2	2	Part D Excluded Drugs	110000000001100000000	30										10	30									31		Part D Excluded Drugs	2	Part D Excluded Drugs																						Part D Excluded Drugs	0.00										0.00	0.00									0.00	1	1	
H5774	005	0	1	01	01	H5774_005_0	4	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5774	005	0	1	01	01	H5774_005_0	4	6	4	1	Part D Excluded Drugs	000010	2	2	2	Part D Excluded Drugs	110000000001100000000	30										10	30									31		Part D Excluded Drugs	2	Part D Excluded Drugs																						Part D Excluded Drugs	0.00										0.00	0.00									0.00			
H5774	008	0	1	01	01	H5774_008_0	4	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5774	008	0	1	01	01	H5774_008_0	4	4	4	3	Non Preferred Brand	100000	1	2	2	Non Preferred Brand																								Non Preferred Brand		Non Preferred Brand																						Non Preferred Brand																						2		
H5774	008	0	1	01	01	H5774_008_0	4	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5774	008	0	1	01	01	H5774_008_0	4	2	4	3	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	10.00	30.00									10.00	10.00	30.00								10.00	1	1	
H5774	008	0	1	01	01	H5774_008_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00									5.00	5.00	15.00								5.00	1	1	
H5774	008	0	1	01	01	H5774_008_0	4	5	4	1	Specialty	010010	1	1	1	Specialty	111000000001110000000	30	90									10	30	90								31	1	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H5774	008	0	1	01	01	H5774_008_0	4	4	4	1	Non Preferred Brand	100000	1	2	2	Non Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	40.00	120.00									40.00	40.00	120.00								40.00			
H5774	008	0	1	01	01	H5774_008_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00	25.00	75.00								25.00			
H5774	008	0	1	01	01	H5774_008_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00									5.00	5.00	15.00								5.00			
H5774	008	0	1	01	01	H5774_008_0	4	2	4	1	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	10.00	30.00									10.00	10.00	30.00								10.00			
H5774	009	0	1	01	01	H5774_009_0	6	4	4	3	Non Preferred Brand	100000	1	2	2	Non Preferred Brand																								Non Preferred Brand		Non Preferred Brand																						Non Preferred Brand																						2		
H5774	009	0	1	01	01	H5774_009_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5774	009	0	1	01	01	H5774_009_0	6	2	4	3	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	10.00	30.00									10.00	10.00	30.00								10.00	1	1	
H5774	009	0	1	01	01	H5774_009_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00									5.00	5.00	15.00								5.00	1	1	
H5774	009	0	1	01	01	H5774_009_0	6	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5774	009	0	1	01	01	H5774_009_0	6	4	4	1	Non Preferred Brand	100000	1	2	2	Non Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	40.00	120.00									40.00	40.00	120.00								40.00			
H5774	009	0	1	01	01	H5774_009_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00	25.00	75.00								25.00			
H5774	009	0	1	01	01	H5774_009_0	6	2	4	1	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	10.00	30.00									10.00	10.00	30.00								10.00			
H5774	009	0	1	01	01	H5774_009_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00									5.00	5.00	15.00								5.00			
H5774	009	0	1	01	01	H5774_009_0	6	5	4	1	Specialty	010010	1	1	1	Specialty	111000000001110000000	30	90									10	30	90								31	1	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H5774	014	0	1	01	01	H5774_014_0	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00									25.00	25.00	75.00								25.00			
H5774	014	0	1	01	01	H5774_014_0	6	4	4	1	Non Preferred Brand	100000	1	2	2	Non Preferred Brand	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	40.00	120.00									40.00	40.00	120.00								40.00			
H5774	014	0	1	01	01	H5774_014_0	6	5	4	1	Specialty	010010	1	1	1	Specialty	111000000001110000000	30	90									10	30	90								31	1	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H5774	014	0	1	01	01	H5774_014_0	6	6	4	1	Part D Excluded Drugs	000010	2	2	2	Part D Excluded Drugs	110000000001100000000	30										10	30									31		Part D Excluded Drugs	2	Part D Excluded Drugs																						Part D Excluded Drugs	0.00										0.00	0.00									0.00			
H5774	014	0	1	01	01	H5774_014_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00									5.00	5.00	15.00								5.00	1	1	
H5774	014	0	1	01	01	H5774_014_0	6	2	4	3	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	10.00	30.00									10.00	10.00	30.00								10.00	1	1	
H5774	014	0	1	01	01	H5774_014_0	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5774	014	0	1	01	01	H5774_014_0	6	4	4	3	Non Preferred Brand	100000	1	2	2	Non Preferred Brand																								Non Preferred Brand		Non Preferred Brand																						Non Preferred Brand																						2		
H5774	014	0	1	01	01	H5774_014_0	6	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5774	014	0	1	01	01	H5774_014_0	6	6	4	3	Part D Excluded Drugs	000010	2	2	2	Part D Excluded Drugs	110000000001100000000	30										10	30									31		Part D Excluded Drugs	2	Part D Excluded Drugs																						Part D Excluded Drugs	0.00										0.00	0.00									0.00	1	1	
H5774	014	0	1	01	01	H5774_014_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00									5.00	5.00	15.00								5.00			
H5774	014	0	1	01	01	H5774_014_0	6	2	4	1	Non Preferred Generic	000100	1	2	2	Non Preferred Generic	111000000001110000000	30	90									10	30	90								31	1	Non Preferred Generic	2	Non Preferred Generic																						Non Preferred Generic	10.00	30.00									10.00	10.00	30.00								10.00			
H5782	001	0	1	01	01	H5782_001_0	3	1	4	3	Generic Tier	010000	1	2	2	Generic Tier	111100000001111000000	30	90	100								29	30	90	100							31	1	Generic Tier	2	Generic Tier																						Generic Tier	0.00	0.00	0.00								0.00	0.00	0.00	0.00							0.00	1	1	
H5782	001	0	1	01	01	H5782_001_0	3	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H5783	002	0	1	01	01	H5783_002_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5783	002	0	1	01	01	H5783_002_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H5783	002	0	1	01	01	H5783_002_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																						2		
H5783	002	0	1	01	01	H5783_002_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5783	002	0	1	01	01	H5783_002_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5783	002	0	1	01	01	H5783_002_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5783	002	0	1	01	01	H5783_002_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	60.00	180.00								60.00			120.00								60.00			
H5783	002	0	1	01	01	H5783_002_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H5783	002	0	1	01	01	H5783_002_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5783	002	0	1	01	01	H5783_002_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H5783	006	0	1	01	01	H5783_006_0	13	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5783	006	0	1	01	01	H5783_006_0	13	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5783	006	0	1	01	01	H5783_006_0	13	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	7.50	22.50								7.50			15.00								7.50			
H5783	006	0	1	01	01	H5783_006_0	13	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5783	006	0	1	01	01	H5783_006_0	13	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5783	006	0	1	01	01	H5783_006_0	13	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5783	006	0	1	01	01	H5783_006_0	13	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5783	006	0	1	01	01	H5783_006_0	13	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5783	006	0	1	01	01	H5783_006_0	13	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5783	006	0	1	01	01	H5783_006_0	13	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																						2		
H5783	009	0	1	01	01	H5783_009_0	8	1	4	1	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00			
H5783	009	0	1	01	01	H5783_009_0	8	4	4	3	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand																								Tier - Non-Preferred Brand		Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand																						2		
H5783	009	0	1	01	01	H5783_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																						2		
H5783	009	0	1	01	01	H5783_009_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5783	009	0	1	01	01	H5783_009_0	8	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5783	009	0	1	01	01	H5783_009_0	8	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5783	009	0	1	01	01	H5783_009_0	8	4	4	1	Tier - Non-Preferred Brand	100000	1	2	1	Tier - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier - Non-Preferred Brand	2	Tier - Non-Preferred Brand																						Tier - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H5783	009	0	1	01	01	H5783_009_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H5783	009	0	1	01	01	H5783_009_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5783	009	0	1	01	01	H5783_009_0	8	1	4	3	Tier 1 - Preferred  Generic	001000	1	2	2	Tier 1 - Preferred  Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred  Generic	2	Tier 1 - Preferred  Generic																						Tier 1 - Preferred  Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H5783	010	0	1	01	01	H5783_010_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H5783	010	0	1	01	01	H5783_010_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H5783	010	0	1	01	01	H5783_010_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5783	010	0	1	01	01	H5783_010_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5783	010	0	1	01	01	H5783_010_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5783	010	0	1	01	01	H5783_010_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H5783	010	0	1	01	01	H5783_010_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5783	010	0	1	01	01	H5783_010_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																						2		
H5783	010	0	1	01	01	H5783_010_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5783	010	0	1	01	01	H5783_010_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5783	012	0	1	01	01	H5783_012_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H5783	012	0	1	01	01	H5783_012_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50	1	1	
H5783	012	0	1	01	01	H5783_012_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5783	012	0	1	01	01	H5783_012_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																						2		
H5783	012	0	1	01	01	H5783_012_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H5783	012	0	1	01	01	H5783_012_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H5783	012	0	1	01	01	H5783_012_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.50	22.50								7.50			15.00								7.50			
H5783	012	0	1	01	01	H5783_012_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
H5783	012	0	1	01	01	H5783_012_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H5783	012	0	1	01	01	H5783_012_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5793	001	0	1	01	01	H5793_001_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					16.00			24.00		8.00			
H5793	001	0	1	01	01	H5793_001_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	33.00	99.00									33.00					66.00			99.00		33.00			
H5793	001	0	1	01	01	H5793_001_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					68.00			102.00		34.00			
H5793	001	0	1	01	01	H5793_001_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	74.00	222.00									74.00					148.00			222.00		74.00			
H5793	001	0	1	01	01	H5793_001_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5793	003	0	1	01	01	H5793_003_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5793	003	0	1	01	01	H5793_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																						2		
H5793	003	0	1	01	01	H5793_003_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5793	003	0	1	01	01	H5793_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																						2		
H5793	003	0	1	01	01	H5793_003_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	15.00	45.00									15.00					30.00			45.00		15.00	1	1	
H5793	003	0	1	01	01	H5793_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
H5793	003	0	1	01	01	H5793_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5793	003	0	1	01	01	H5793_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	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	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					10.00			15.00		5.00			
H5793	003	0	1	01	01	H5793_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H5793	008	0	1	01	01	H5793_008_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H5793	008	0	1	01	01	H5793_008_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	33.00	99.00									33.00					66.00			99.00		33.00			
H5793	008	0	1	01	01	H5793_008_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					64.00			96.00		32.00			
H5793	008	0	1	01	01	H5793_008_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H5793	008	0	1	01	01	H5793_008_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5810	001	0	1	01	01	H5810_001_0	11	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5810	001	0	1	01	01	H5810_001_0	11	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5810	001	0	1	01	01	H5810_001_0	11	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H5810	001	0	1	01	01	H5810_001_0	11	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5810	002	0	1	01	01	H5810_002_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00								20.00			60.00								20.00			
H5810	002	0	1	01	01	H5810_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H5810	002	0	1	01	01	H5810_002_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H5810	007	0	1	01	01	H5810_007_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5810	007	0	1	01	01	H5810_007_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H5810	007	0	1	01	01	H5810_007_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5810	007	0	1	01	01	H5810_007_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5810	008	0	1	01	01	H5810_008_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H5810	008	0	1	01	01	H5810_008_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5810	008	0	1	01	01	H5810_008_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5810	008	0	1	01	01	H5810_008_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5810	009	0	1	01	01	H5810_009_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H5810	009	0	1	01	01	H5810_009_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H5810	009	0	1	01	01	H5810_009_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H5810	009	0	1	01	01	H5810_009_0	5	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H5811	001	0	1	01	01	H5811_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	34	90									29	34	90								34	2	Generic	2	Generic																						Generic	9.00	18.00									9.00	9.00	18.00								9.00			
H5811	001	0	1	01	01	H5811_001_0	4	3	4	1	Specialty	010010	1	1	1	Specialty	111000000001110000000	34	90									29	34	90								34	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H5811	001	0	1	01	01	H5811_001_0	4	2	4	1	Brand	000010	1	2	2	Brand	111000000001110000000	34	90									29	34	90								34	2	Brand	2	Brand																						Brand	39.00	78.00									39.00	39.00	78.00								39.00			
H5811	001	0	1	01	01	H5811_001_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000001110000000	34	90									29	34	90								34	2	Generic	2	Generic																						Generic	9.00	18.00									9.00	9.00	18.00								9.00	1	1	
H5811	001	0	1	01	01	H5811_001_0	4	2	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5811	001	0	1	01	01	H5811_001_0	4	3	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5811	002	0	1	01	01	H5811_002_0	7	2	4	1	Brand	000010	1	2	2	Brand	111000000001110000000	34	90									29	34	90								34	2	Brand	2	Brand																						Brand	45.00	90.00									45.00	45.00	90.00								45.00			
H5811	002	0	1	01	01	H5811_002_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	34	90									29	34	90								34	2	Generic	2	Generic																						Generic	0.00	0.00									0.00	0.00	0.00								0.00			
H5811	002	0	1	01	01	H5811_002_0	7	3	4	1	Specialty	010010	1	1	1	Specialty	111000000001110000000	34	90									29	34	90								34	2	Specialty	1	Specialty	25	25									25	25	25								25	Specialty																								
H5812	044	0	1	09	04	H5812_044_0	5	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H5812	044	0	1	09	04	H5812_044_0	5	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H5812	044	0	1	09	04	H5812_044_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	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	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H5812	054	0	1	09	04	H5812_054_0	3	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	6.00	18.00								6.00			15.00								6.00			
H5812	054	0	1	09	04	H5812_054_0	3	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			172.50								69.00			
H5812	054	0	1	09	04	H5812_054_0	3	4	4	1	Tier 4	100000	1	1	2	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H5812	054	0	1	09	04	H5812_054_0	3	2	4	1	Tier 2	000011	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			97.50								39.00			
H5813	003	0	1	01	01	H5813_003_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H5813	003	0	1	01	01	H5813_003_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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	003	0	1	01	01	H5813_003_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5813	003	0	1	01	01	H5813_003_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	003	0	1	01	01	H5813_003_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H5813	006	0	1	01	01	H5813_006_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H5813	006	0	1	01	01	H5813_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																						2		
H5813	006	0	1	01	01	H5813_006_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic																								Tier 2 - Non-Preferred Generic		Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic																						2		
H5813	006	0	1	01	01	H5813_006_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				15.00	37.50		15.00	45.00			15.00					30.00			45.00		15.00	1	1	
H5813	006	0	1	01	01	H5813_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																						2		
H5813	006	0	1	01	01	H5813_006_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H5813	006	0	1	01	01	H5813_006_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H5813	006	0	1	01	01	H5813_006_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				30.00	75.00		30.00	90.00			30.00					60.00			90.00		30.00			
H5813	006	0	1	01	01	H5813_006_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
H5817	009	0	1	01	01	H5817_009_0	3	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H5817	009	0	1	01	01	H5817_009_0	3	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5817	009	0	1	01	01	H5817_009_0	3	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5817	009	0	1	01	01	H5817_009_0	3	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5817	009	0	1	01	01	H5817_009_0	3	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5817	009	0	1	01	01	H5817_009_0	3	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5817	009	0	1	01	01	H5817_009_0	3	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H5817	009	0	1	01	01	H5817_009_0	3	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H5817	010	0	1	01	01	H5817_010_0	3	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	3	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	3	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5817	010	0	1	01	01	H5817_010_0	3	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5817	010	0	1	01	01	H5817_010_0	3	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5817	010	0	1	01	01	H5817_010_0	3	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5817	010	0	1	01	01	H5817_010_0	3	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5817	010	0	1	01	01	H5817_010_0	3	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H5817	010	0	1	01	01	H5817_010_0	3	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	70.00	210.00	140.00							70.00		70.00	140.00	105.00							70.00			
H5817	010	0	1	01	01	H5817_010_0	3	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00	60.00							30.00		30.00	60.00	45.00							30.00			
H5817	011	0	1	01	01	H5817_011_0	4	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	4	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5817	011	0	1	01	01	H5817_011_0	4	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5817	011	0	1	01	01	H5817_011_0	4	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5817	011	0	1	01	01	H5817_011_0	4	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5817	011	0	1	01	01	H5817_011_0	4	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H5817	011	0	1	01	01	H5817_011_0	4	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	60.00	180.00	120.00							60.00		60.00	120.00	90.00							60.00			
H5817	011	0	1	01	01	H5817_011_0	4	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	20.00	60.00	40.00							20.00		20.00	40.00	30.00							20.00			
H5817	011	0	1	01	01	H5817_011_0	4	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	4	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5820	002	0	1	09	04	H5820_002_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00			
H5820	002	0	1	09	04	H5820_002_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5820	002	0	1	09	04	H5820_002_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5820	002	0	1	09	04	H5820_002_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5820	002	0	1	09	04	H5820_002_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	003	0	1	09	04	H5820_003_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	003	0	1	09	04	H5820_003_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00			
H5820	003	0	1	09	04	H5820_003_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5820	003	0	1	09	04	H5820_003_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5820	003	0	1	09	04	H5820_003_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5820	004	0	1	09	04	H5820_004_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5820	004	0	1	09	04	H5820_004_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	004	0	1	09	04	H5820_004_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5820	004	0	1	09	04	H5820_004_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00			
H5820	004	0	1	09	04	H5820_004_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5820	008	0	1	09	04	H5820_008_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	008	0	1	09	04	H5820_008_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5820	008	0	1	09	04	H5820_008_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5820	008	0	1	09	04	H5820_008_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	2.00	6.00	4.00							2.00		2.00	4.00	4.00							2.00			
H5820	008	0	1	09	04	H5820_008_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	14.00	14.00							7.00			
H5820	009	0	1	09	04	H5820_009_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5820	009	0	1	09	04	H5820_009_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5820	009	0	1	09	04	H5820_009_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	14.00	14.00							7.00			
H5820	009	0	1	09	04	H5820_009_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	2.00	6.00	4.00							2.00		2.00	4.00	4.00							2.00			
H5820	009	0	1	09	04	H5820_009_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	010	0	1	09	04	H5820_010_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	14.00	14.00							7.00			
H5820	010	0	1	09	04	H5820_010_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	2.00	6.00	4.00							2.00		2.00	4.00	4.00							2.00			
H5820	010	0	1	09	04	H5820_010_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5820	010	0	1	09	04	H5820_010_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	010	0	1	09	04	H5820_010_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5820	011	0	1	09	04	H5820_011_0	5	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	4.00	12.00	8.00							4.00		4.00	8.00	8.00							4.00			
H5820	011	0	1	09	04	H5820_011_0	5	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	10.00	30.00	20.00							10.00		10.00	20.00	20.00							10.00			
H5820	011	0	1	09	04	H5820_011_0	5	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
H5820	011	0	1	09	04	H5820_011_0	5	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00	70.00							35.00		35.00	70.00	70.00							35.00			
H5820	011	0	1	09	04	H5820_011_0	5	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	013	0	1	09	04	H5820_013_0	4	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H5820	013	0	1	09	04	H5820_013_0	4	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H5820	013	0	1	09	04	H5820_013_0	4	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
H5820	013	0	1	09	04	H5820_013_0	4	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	2.00	6.00	4.00							2.00		2.00	4.00	4.00							2.00			
H5820	013	0	1	09	04	H5820_013_0	4	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	7.00	21.00	14.00							7.00		7.00	14.00	14.00							7.00			
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																						2		
H5821	001	0	1	02	01	H5821_001_0	5	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Generic Drugs	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	2	Preferred Brand Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Preferred Brand Drugs	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	1	Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Non-Preferred Brand Drugs	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	2	Specialty Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Specialty Drugs	1	Specialty Drugs	25	25	25								25	25	25								25	Specialty Drugs																								
H5821	001	0	1	02	01	H5821_001_0	5	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00	1	1	
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																						2		
H5821	001	0	1	02	01	H5821_001_0	5	3	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5821	004	0	1	02	01	H5821_004_0	5	3	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5821	004	0	1	02	01	H5821_004_0	5	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Generic Drugs	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	2	Preferred Brand Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00	25.00								25.00	25.00	75.00								25.00			
H5821	004	0	1	02	01	H5821_004_0	5	3	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	35.00	105.00	35.00								35.00	35.00	105.00								35.00			
H5821	004	0	1	02	01	H5821_004_0	5	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Specialty Drugs	1	Specialty Drugs	25	25	25								25	25	25								25	Specialty Drugs																								
H5821	004	0	1	02	01	H5821_004_0	5	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00	1	1	
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																						2		
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																						2		
H5821	013	0	1	02	01	H5821_013_0	8	4	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5821	013	0	1	02	01	H5821_013_0	8	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Generic Drugs	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	8	2	4	1	Preferred Brand Drugs	000001	3	2	2	Preferred Brand Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00	25.00								25.00	25.00	75.00								25.00			
H5821	013	0	1	02	01	H5821_013_0	8	3	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	35.00	105.00	35.00								35.00	35.00	105.00								35.00			
H5821	013	0	1	02	01	H5821_013_0	8	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Specialty Drugs	1	Specialty Drugs	30	30	30								30	30	30								30	Specialty Drugs																								
H5821	013	0	1	02	01	H5821_013_0	8	1	4	3	Generic Drugs	010000	1	2	2	Generic Drugs	111100000001110000000	30	90	15								15	30	90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	3.00	9.00	3.00								3.00	3.00	9.00								3.00	1	1	
H5821	013	0	1	02	01	H5821_013_0	8	2	4	3	Preferred Brand Drugs	000001	3	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5821	013	0	1	02	01	H5821_013_0	8	3	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5823	002	0	1	01	01	H5823_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	5	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H5823	002	0	1	01	01	H5823_002_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H5823	002	0	1	01	01	H5823_002_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H5823	004	0	1	01	01	H5823_004_0	5	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H5823	004	0	1	01	01	H5823_004_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H5823	004	0	1	01	01	H5823_004_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H5823	004	0	1	01	01	H5823_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H5826	008	0	1	01	01	H5826_008_0	4	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	34	90								34			90								34	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	13.00	39.00								13.00			39.00								13.00			
H5826	008	0	1	01	01	H5826_008_0	4	2	3	1	Tier 2 - Brand	000010		2	2	Tier 2 - Brand	111000000010010000000	34	90								34			90								34	1	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	45.00	135.00								45.00			135.00								45.00			
H5826	008	0	1	01	01	H5826_008_0	4	3	3	1	Tier 3 - Specialty	100000		1	1	Tier 3 - Specialty	111000000010010000000	34	90								34			90								34	1	Tier 3 - Specialty	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																								
H5826	009	0	1	01	01	H5826_009_0	4	3	3	1	Tier 3 - Specialty	100000		1	1	Tier 3 - Specialty	111000000010010000000	34	90								34			90								34	1	Tier 3 - Specialty	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																								
H5826	009	0	1	01	01	H5826_009_0	4	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	34	90								34			90								34	1	Tier 1 - Generic	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	4	2	3	1	Tier 2 - Brand	000010		2	2	Tier 2 - Brand	111000000010010000000	34	90								34			90								34	1	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	39.00	117.00								39.00			117.00								39.00			
H5826	010	0	1	01	01	H5826_010_0	8	3	4	3	Tier 3 - Specialty	010010	1	1	1	Tier 3 - Specialty																								Tier 3 - Specialty		Tier 3 - Specialty																						Tier 3 - Specialty																						2		
H5826	010	0	1	01	01	H5826_010_0	8	2	4	3	Tier 2 - Brand	000010	1	2	2	Tier 2 - Brand																								Tier 2 - Brand		Tier 2 - Brand																						Tier 2 - Brand																						2		
H5826	010	0	1	01	01	H5826_010_0	8	3	4	1	Tier 3 - Specialty	010010	1	1	1	Tier 3 - Specialty	111000000010010000000	34	90								34			90								34	1	Tier 3 - Specialty	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																								
H5826	010	0	1	01	01	H5826_010_0	8	2	4	1	Tier 2 - Brand	000010	1	2	2	Tier 2 - Brand	111000000010010000000	34	90								34			90								34	1	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	45.00	135.00								45.00			135.00								45.00			
H5826	010	0	1	01	01	H5826_010_0	8	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	34	90								34			90								34	1	Tier 1 - Generic	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	8	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	34	90								34			90								34	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			15.00								5.00	1	1	
H5826	011	0	1	02	01	H5826_011_0	6	3	4	3	Tier 3 - Specialty	010010	1	1	1	Tier 3 - Specialty																								Tier 3 - Specialty		Tier 3 - Specialty																						Tier 3 - Specialty																						2		
H5826	011	0	1	02	01	H5826_011_0	6	2	4	3	Tier 2 - Brand	000010	1	2	2	Tier 2 - Brand																								Tier 2 - Brand		Tier 2 - Brand																						Tier 2 - Brand																						2		
H5826	011	0	1	02	01	H5826_011_0	6	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	34	90								34			90								34	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			15.00								5.00	1	1	
H5826	011	0	1	02	01	H5826_011_0	6	3	4	1	Tier 3 - Specialty	010010	1	1	1	Tier 3 - Specialty	111000000010010000000	34	90								34			90								34	1	Tier 3 - Specialty	1	Tier 3 - Specialty	33	33								33			33								33	Tier 3 - Specialty																								
H5826	011	0	1	02	01	H5826_011_0	6	2	4	1	Tier 2 - Brand	000010	1	2	2	Tier 2 - Brand	111000000010010000000	34	90								34			90								34	1	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	40.00	120.00								40.00			120.00								40.00			
H5826	011	0	1	02	01	H5826_011_0	6	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	34	90								34			90								34	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			15.00								5.00			
H5832	001	0	1	01	01	H5832_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H5832	001	0	1	01	01	H5832_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H5832	001	0	1	01	01	H5832_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					76.00			114.00		38.00			
H5832	001	0	1	01	01	H5832_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5832	001	0	1	01	01	H5832_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					56.00			84.00		28.00			
H5839	001	0	1	09	04	H5839_001_0	8	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H5839	001	0	1	09	04	H5839_001_0	8	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
H5839	001	0	1	09	04	H5839_001_0	8	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H5850	001	0	1	01	01	H5850_001_0	7	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	001	0	1	01	01	H5850_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00			
H5850	001	0	1	01	01	H5850_001_0	7	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H5850	001	0	1	01	01	H5850_001_0	7	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	001	0	1	01	01	H5850_001_0	7	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	001	0	1	01	01	H5850_001_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	001	0	1	01	01	H5850_001_0	7	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	001	0	1	01	01	H5850_001_0	7	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	002	0	1	01	01	H5850_002_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	002	0	1	01	01	H5850_002_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	002	0	1	01	01	H5850_002_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	002	0	1	01	01	H5850_002_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	002	0	1	01	01	H5850_002_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	25									25											25	Specialty Drugs																								
H5850	002	0	1	01	01	H5850_002_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00			
H5850	002	0	1	01	01	H5850_002_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H5850	002	0	1	01	01	H5850_002_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	003	0	1	01	01	H5850_003_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	003	0	1	01	01	H5850_003_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H5850	003	0	1	01	01	H5850_003_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	003	0	1	01	01	H5850_003_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	003	0	1	01	01	H5850_003_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	003	0	1	01	01	H5850_003_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	003	0	1	01	01	H5850_003_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	003	0	1	01	01	H5850_003_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	30.00								15.00			30.00								15.00			
H5850	004	0	1	01	01	H5850_004_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	50.00								25.00			50.00								25.00			
H5850	004	0	1	01	01	H5850_004_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	004	0	1	01	01	H5850_004_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H5850	004	0	1	01	01	H5850_004_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
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																						2		
H5850	004	0	1	01	01	H5850_004_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	004	0	1	01	01	H5850_004_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
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																						2		
H5850	005	0	1	01	01	H5850_005_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	005	0	1	01	01	H5850_005_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00			60.00								30.00			
H5850	005	0	1	01	01	H5850_005_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	89.00	267.00								89.00			267.00								89.00			
H5850	005	0	1	01	01	H5850_005_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	006	0	1	01	01	H5850_006_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	006	0	1	01	01	H5850_006_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H5850	006	0	1	01	01	H5850_006_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00			
H5850	006	0	1	01	01	H5850_006_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	006	0	1	01	01	H5850_006_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	006	0	1	01	01	H5850_006_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	006	0	1	01	01	H5850_006_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	006	0	1	01	01	H5850_006_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	007	0	1	01	01	H5850_007_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	007	0	1	01	01	H5850_007_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	007	0	1	01	01	H5850_007_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	007	0	1	01	01	H5850_007_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	007	0	1	01	01	H5850_007_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H5850	007	0	1	01	01	H5850_007_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	007	0	1	01	01	H5850_007_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	007	0	1	01	01	H5850_007_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00			40.00								20.00			
H5850	010	0	1	01	01	H5850_010_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	77.00	231.00								77.00			231.00								77.00			
H5850	010	0	1	01	01	H5850_010_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	010	0	1	01	01	H5850_010_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H5850	010	0	1	01	01	H5850_010_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	012	0	1	01	01	H5850_012_0	6	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	012	0	1	01	01	H5850_012_0	6	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	012	0	1	01	01	H5850_012_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00			
H5850	012	0	1	01	01	H5850_012_0	6	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H5850	012	0	1	01	01	H5850_012_0	6	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	012	0	1	01	01	H5850_012_0	6	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	012	0	1	01	01	H5850_012_0	6	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	012	0	1	01	01	H5850_012_0	6	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	015	0	1	01	01	H5850_015_0	5	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	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	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	5.00	10.00								5.00			10.00								5.00			
H5850	015	0	1	01	01	H5850_015_0	5	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5850	015	0	1	01	01	H5850_015_0	5	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	015	0	1	01	01	H5850_015_0	5	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
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																						2		
H5850	015	0	1	01	01	H5850_015_0	5	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
H5850	016	0	1	01	01	H5850_016_0	5	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	016	0	1	01	01	H5850_016_0	5	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	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	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H5850	016	0	1	01	01	H5850_016_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	40.00								20.00			40.00								20.00			
H5850	016	0	1	01	01	H5850_016_0	5	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	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																						2		
H5850	016	0	1	01	01	H5850_016_0	5	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
H5850	017	0	1	02	01	H5850_017_0	7	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	017	0	1	02	01	H5850_017_0	7	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	017	0	1	02	01	H5850_017_0	7	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H5850	017	0	1	02	01	H5850_017_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H5850	017	0	1	02	01	H5850_017_0	7	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	017	0	1	02	01	H5850_017_0	7	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	017	0	1	02	01	H5850_017_0	7	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	017	0	1	02	01	H5850_017_0	7	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	019	0	1	01	01	H5850_019_0	5	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00			
H5850	019	0	1	01	01	H5850_019_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H5850	019	0	1	01	01	H5850_019_0	5	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	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	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	020	0	1	01	01	H5850_020_0	5	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	020	0	1	01	01	H5850_020_0	5	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	020	0	1	01	01	H5850_020_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	020	0	1	01	01	H5850_020_0	5	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	33									33											33	Specialty Drugs																								
H5850	020	0	1	01	01	H5850_020_0	5	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H5850	020	0	1	01	01	H5850_020_0	5	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5850	020	0	1	01	01	H5850_020_0	5	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	020	0	1	01	01	H5850_020_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	5.00	10.00								5.00			10.00								5.00			
H5850	021	0	1	01	01	H5850_021_0	5	1	4	1	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5850	021	0	1	01	01	H5850_021_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	80.00								40.00			80.00								40.00			
H5850	021	0	1	01	01	H5850_021_0	5	3	4	1	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	228.00								76.00			228.00								76.00			
H5850	021	0	1	01	01	H5850_021_0	5	4	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000000000	30									30											31		Specialty Drugs	1	Specialty Drugs	25									25											25	Specialty Drugs																								
H5850	021	0	1	01	01	H5850_021_0	5	1	4	3	Preferred Generic	001001	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5850	021	0	1	01	01	H5850_021_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5850	021	0	1	01	01	H5850_021_0	5	3	4	3	Non-Preferred Brand	100100	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5850	021	0	1	01	01	H5850_021_0	5	4	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5854	002	0	1	01	01	H5854_002_0	7	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5854	002	0	1	01	01	H5854_002_0	7	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5854	002	0	1	01	01	H5854_002_0	7	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5854	002	0	1	01	01	H5854_002_0	7	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5854	002	0	1	01	01	H5854_002_0	7	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5854	002	0	1	01	01	H5854_002_0	7	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5854	002	0	1	01	01	H5854_002_0	7	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						200.00			240.00		80.00			
H5854	002	0	1	01	01	H5854_002_0	7	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						105.00			126.00		42.00			
H5854	002	0	1	01	01	H5854_002_0	7	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5854	002	0	1	01	01	H5854_002_0	7	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5854	003	0	1	01	01	H5854_003_0	7	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5854	003	0	1	01	01	H5854_003_0	7	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5854	003	0	1	01	01	H5854_003_0	7	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5854	003	0	1	01	01	H5854_003_0	7	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5854	003	0	1	01	01	H5854_003_0	7	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5854	003	0	1	01	01	H5854_003_0	7	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5854	003	0	1	01	01	H5854_003_0	7	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						200.00			240.00		80.00			
H5854	003	0	1	01	01	H5854_003_0	7	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5854	003	0	1	01	01	H5854_003_0	7	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5854	003	0	1	01	01	H5854_003_0	7	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						105.00			126.00		42.00			
H5854	005	0	1	01	01	H5854_005_0	7	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H5854	005	0	1	01	01	H5854_005_0	7	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H5854	005	0	1	01	01	H5854_005_0	7	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H5854	005	0	1	01	01	H5854_005_0	7	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H5854	005	0	1	01	01	H5854_005_0	7	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
H5854	005	0	1	01	01	H5854_005_0	7	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H5854	005	0	1	01	01	H5854_005_0	7	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H5854	005	0	1	01	01	H5854_005_0	7	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						105.00			126.00		42.00			
H5854	005	0	1	01	01	H5854_005_0	7	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	80.00	240.00								80.00						200.00			240.00		80.00			
H5854	005	0	1	01	01	H5854_005_0	7	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
H5859	001	0	1	01	01	H5859_001_0	3	2	4	1	2	000011	1	2	1	2	111000000010110000000	34	90								34		34	90								34	1	2	1	2	41	41								41		41	41								41	2																								
H5859	001	0	1	01	01	H5859_001_0	3	1	4	1	1	010000	1	2	2	1	111000000010110000000	34	90								34		34	90								34	1	1	2	1																						1	0.00	0.00								0.00		0.00	0.00								0.00			
H5859	001	0	1	01	01	H5859_001_0	3	3	4	1	3	010010	1	1	2	3	110000000010100000000	34									34		34									34		3	1	3	25									25		25									25	3																								
H5859	003	0	1	01	01	H5859_003_0	3	3	4	1	3	010010	1	1	2	3	110000000010100000000	34									34		34									34		3	1	3	25									25		25									25	3																								
H5859	003	0	1	01	01	H5859_003_0	3	1	4	1	1	010000	1	2	2	1	111000000010110000000	34	90								34		34	90								34	1	1	2	1																						1	0.00	0.00								0.00		0.00	0.00								0.00			
H5859	003	0	1	01	01	H5859_003_0	3	1	4	3	1	010000	1	2	2	1	111000000010110000000	34	90								34		34	90								34	1	1	2	1																						1	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H5859	003	0	1	01	01	H5859_003_0	3	2	4	3	2	000011	1	2	1	2																								2		2																						2																						2		
H5859	003	0	1	01	01	H5859_003_0	3	3	4	3	3	010010	1	1	2	3																								3		3																						3																						2		
H5859	003	0	1	01	01	H5859_003_0	3	2	4	1	2	000011	1	2	1	2	111000000010110000000	34	90								34		34	90								34	1	2	2	2																						2	45.00	135.00								45.00		45.00	112.50								45.00			
H5862	001	0	1	09	04	H5862_001_0	5	4	4	1	Tier 4 - Injectable Drugs	101101	1	2	2	Tier 4 - Injectable Drugs	111000000010110000000	30	90								30		30	90								31	1	Tier 4 - Injectable Drugs	1	Tier 4 - Injectable Drugs	25	25								25		25	25								25	Tier 4 - Injectable Drugs																								
H5862	001	0	1	09	04	H5862_001_0	5	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00			
H5862	001	0	1	09	04	H5862_001_0	5	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Tier 2 - Preferred Brand	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	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010110000000	30	90								30		30	90								31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00								5.00		5.00	15.00								5.00			
H5862	001	0	1	09	04	H5862_001_0	5	5	4	1	Tier 5 - Specialty Drugs	101101	1	1	2	Tier 5 - Specialty Drugs	111000000010110000000	30	90								30		30	90								31	1	Tier 5 - Specialty Drugs	1	Tier 5 - Specialty Drugs	25	25								25		25	25								25	Tier 5 - Specialty Drugs																								
H5868	001	0	1	04	01	H5868_001_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5868	001	0	1	04	01	H5868_001_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5868	001	0	1	04	01	H5868_001_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5868	001	0	1	04	01	H5868_001_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5868	001	0	1	04	01	H5868_001_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5868	001	0	1	04	01	H5868_001_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5868	001	0	1	04	01	H5868_001_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5883	002	1	1	01	01	H5883_002_1	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00		35.00	87.50								35.00			
H5883	002	1	1	01	01	H5883_002_1	9	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non Preferred	2	Non Preferred																						Non Preferred				75.00	187.50		75.00	225.00		75.00		75.00	187.50								75.00			
H5883	002	1	1	01	01	H5883_002_1	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	10.00		4.00	12.00		4.00		4.00	10.00								4.00			
H5883	002	1	1	01	01	H5883_002_1	9	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	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	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	002	2	1	01	01	H5883_002_2	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00		35.00	87.50								35.00			
H5883	002	2	1	01	01	H5883_002_2	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	10.00		4.00	12.00		4.00		4.00	10.00								4.00			
H5883	002	2	1	01	01	H5883_002_2	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non Preferred	2	Non Preferred																						Non Preferred				75.00	187.50		75.00	225.00		75.00		75.00	187.50								75.00			
H5883	002	2	1	01	01	H5883_002_2	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	002	2	1	01	01	H5883_002_2	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	002	3	1	01	01	H5883_002_3	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00		35.00	87.50								35.00			
H5883	002	3	1	01	01	H5883_002_3	10	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non Preferred	2	Non Preferred																						Non Preferred				75.00	187.50		75.00	225.00		75.00		75.00	187.50								75.00			
H5883	002	3	1	01	01	H5883_002_3	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	002	3	1	01	01	H5883_002_3	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	002	3	1	01	01	H5883_002_3	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	10.00		4.00	12.00		4.00		4.00	10.00								4.00			
H5883	002	4	1	01	01	H5883_002_4	9	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	002	4	1	01	01	H5883_002_4	9	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	002	4	1	01	01	H5883_002_4	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00		35.00	87.50								35.00			
H5883	002	4	1	01	01	H5883_002_4	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	10.00		4.00	12.00		4.00		4.00	10.00								4.00			
H5883	002	4	1	01	01	H5883_002_4	9	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non Preferred	2	Non Preferred																						Non Preferred				75.00	187.50		75.00	225.00		75.00		75.00	187.50								75.00			
H5883	002	7	1	01	01	H5883_002_7	11	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	10.00		4.00	12.00		4.00		4.00	10.00								4.00			
H5883	002	7	1	01	01	H5883_002_7	11	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	87.50		35.00	105.00		35.00		35.00	87.50								35.00			
H5883	002	7	1	01	01	H5883_002_7	11	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non Preferred	2	Non Preferred																						Non Preferred				75.00	187.50		75.00	225.00		75.00		75.00	187.50								75.00			
H5883	002	7	1	01	01	H5883_002_7	11	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	002	7	1	01	01	H5883_002_7	11	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	003	1	1	01	01	H5883_003_1	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00			
H5883	003	1	1	01	01	H5883_003_1	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred				65.00	162.50		65.00	195.00		65.00		65.00	162.50								65.00			
H5883	003	1	1	01	01	H5883_003_1	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	003	1	1	01	01	H5883_003_1	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	003	1	1	01	01	H5883_003_1	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00	1	1	
H5883	003	1	1	01	01	H5883_003_1	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5883	003	1	1	01	01	H5883_003_1	10	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5883	003	1	1	01	01	H5883_003_1	10	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5883	003	1	1	01	01	H5883_003_1	10	5	4	3	Injectable	010010	1	2	2	Injectable																								Injectable		Injectable																						Injectable																						2		
H5883	003	2	1	01	01	H5883_003_2	10	5	4	3	Injectable	010010	1	2	2	Injectable																								Injectable		Injectable																						Injectable																						2		
H5883	003	2	1	01	01	H5883_003_2	10	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5883	003	2	1	01	01	H5883_003_2	10	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5883	003	2	1	01	01	H5883_003_2	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5883	003	2	1	01	01	H5883_003_2	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	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	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	003	2	1	01	01	H5883_003_2	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	003	2	1	01	01	H5883_003_2	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred				65.00	162.50		65.00	195.00		65.00		65.00	162.50								65.00			
H5883	003	2	1	01	01	H5883_003_2	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00			
H5883	003	2	1	01	01	H5883_003_2	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00	1	1	
H5883	003	3	1	01	01	H5883_003_3	10	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5883	003	3	1	01	01	H5883_003_3	10	5	4	3	Injectable	010010	1	2	2	Injectable																								Injectable		Injectable																						Injectable																						2		
H5883	003	3	1	01	01	H5883_003_3	10	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5883	003	3	1	01	01	H5883_003_3	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5883	003	3	1	01	01	H5883_003_3	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00	1	1	
H5883	003	3	1	01	01	H5883_003_3	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	003	3	1	01	01	H5883_003_3	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	003	3	1	01	01	H5883_003_3	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred				65.00	162.50		65.00	195.00		65.00		65.00	162.50								65.00			
H5883	003	3	1	01	01	H5883_003_3	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00			
H5883	003	3	1	01	01	H5883_003_3	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	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	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	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	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00			
H5883	003	4	1	01	01	H5883_003_4	10	5	4	3	Injectable	010010	1	2	2	Injectable																								Injectable		Injectable																						Injectable																						2		
H5883	003	4	1	01	01	H5883_003_4	10	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5883	003	4	1	01	01	H5883_003_4	10	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5883	003	4	1	01	01	H5883_003_4	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5883	003	4	1	01	01	H5883_003_4	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00	1	1	
H5883	003	4	1	01	01	H5883_003_4	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	003	4	1	01	01	H5883_003_4	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	003	4	1	01	01	H5883_003_4	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred				65.00	162.50		65.00	195.00		65.00		65.00	162.50								65.00			
H5883	003	5	1	01	01	H5883_003_5	10	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				3.00	7.50		3.00	9.00		3.00		3.00	7.50								3.00			
H5883	003	5	1	01	01	H5883_003_5	10	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5883	003	5	1	01	01	H5883_003_5	10	3	4	3	Non-Preferred	100100	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5883	003	5	1	01	01	H5883_003_5	10	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5883	003	5	1	01	01	H5883_003_5	10	5	4	3	Injectable	010010	1	2	2	Injectable																								Injectable		Injectable																						Injectable																						2		
H5883	003	5	1	01	01	H5883_003_5	10	5	4	1	Injectable	010010	1	2	2	Injectable	100010010010000000000				34			34			34											34		Injectable	1	Injectable				25			25			25											25	Injectable																								
H5883	003	5	1	01	01	H5883_003_5	10	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010100000000				34			34			34		34									34		Specialty	1	Specialty				25			25			25		25									25	Specialty																								
H5883	003	5	1	01	01	H5883_003_5	10	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010110000000				34	90		34	90		34		34	90								34	1	Non-Preferred	2	Non-Preferred																						Non-Preferred				65.00	162.50		65.00	195.00		65.00		65.00	162.50								65.00			
H5883	003	5	1	01	01	H5883_003_5	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				30.00	75.00		30.00	90.00		30.00		30.00	75.00								30.00			
H5883	003	5	1	01	01	H5883_003_5	10	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010110000000				34	90		34	90		34		34	90								34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	12.50		5.00	15.00		5.00		5.00	12.50								5.00	1	1	
H5884	003	1	1	09	04	H5884_003_1	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H5884	003	1	1	09	04	H5884_003_1	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H5884	003	1	1	09	04	H5884_003_1	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H5884	003	1	1	09	04	H5884_003_1	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H5884	003	1	1	09	04	H5884_003_1	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H5884	003	2	1	09	04	H5884_003_2	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H5884	003	2	1	09	04	H5884_003_2	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H5884	003	2	1	09	04	H5884_003_2	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H5884	003	2	1	09	04	H5884_003_2	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H5884	003	2	1	09	04	H5884_003_2	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H5884	004	1	1	09	04	H5884_004_1	5	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H5884	004	1	1	09	04	H5884_004_1	5	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H5884	004	1	1	09	04	H5884_004_1	5	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H5884	004	1	1	09	04	H5884_004_1	5	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H5884	004	1	1	09	04	H5884_004_1	5	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H5884	004	2	1	09	04	H5884_004_2	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H5884	004	2	1	09	04	H5884_004_2	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H5884	004	2	1	09	04	H5884_004_2	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H5884	004	2	1	09	04	H5884_004_2	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H5884	004	2	1	09	04	H5884_004_2	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H5887	001	0	1	01	01	H5887_001_0	5	2	4	3	2	000001	1	2	2	2																								2		2																						2																						2		
H5887	001	0	1	01	01	H5887_001_0	5	1	4	1	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00			
H5887	001	0	1	01	01	H5887_001_0	5	2	4	1	2	000001	1	2	2	2	111000000010000000000	30	90								30											31	2	2	2	2																						2	15.00	45.00								15.00											15.00			
H5887	001	0	1	01	01	H5887_001_0	5	3	4	1	3	100000	1	2	1	3	111000000010000000000	30	90								30											31	2	3	2	3																						3	30.00	90.00								30.00											30.00			
H5887	001	0	1	01	01	H5887_001_0	5	1	4	3	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00	1	1	
H5887	001	0	1	01	01	H5887_001_0	5	4	4	1	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																								
H5887	001	0	1	01	01	H5887_001_0	5	4	4	3	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																						1	2	01000000
H5887	001	0	1	01	01	H5887_001_0	5	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
H5887	006	0	1	01	01	H5887_006_0	5	4	4	1	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																								
H5887	006	0	1	01	01	H5887_006_0	5	1	4	3	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00	1	1	
H5887	006	0	1	01	01	H5887_006_0	5	1	4	1	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	0.00	0.00								0.00											0.00			
H5887	006	0	1	01	01	H5887_006_0	5	2	4	1	2	000001	1	2	2	2	111000000010000000000	30	90								30											31	2	2	2	2																						2	8.00	24.00								8.00											8.00			
H5887	006	0	1	01	01	H5887_006_0	5	3	4	1	3	100000	1	2	1	3	111000000010000000000	30	90								30											31	2	3	2	3																						3	20.00	60.00								20.00											20.00			
H5887	006	0	1	01	01	H5887_006_0	5	2	4	3	2	000001	1	2	2	2																								2		2																						2																						2		
H5887	006	0	1	01	01	H5887_006_0	5	4	4	3	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																						1	2	01000000
H5887	006	0	1	01	01	H5887_006_0	5	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
H5887	007	0	1	01	01	H5887_007_0	5	1	4	3	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	5.00	15.00								5.00											5.00	1	1	
H5887	007	0	1	01	01	H5887_007_0	5	4	4	1	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																								
H5887	007	0	1	01	01	H5887_007_0	5	3	4	1	3	100000	1	2	1	3	111000000010000000000	30	90								30											31	2	3	2	3																						3	30.00	90.00								30.00											30.00			
H5887	007	0	1	01	01	H5887_007_0	5	2	4	1	2	000001	1	2	2	2	111000000010000000000	30	90								30											31	2	2	2	2																						2	20.00	60.00								20.00											20.00			
H5887	007	0	1	01	01	H5887_007_0	5	1	4	1	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	5.00	15.00								5.00											5.00			
H5887	007	0	1	01	01	H5887_007_0	5	2	4	3	2	000001	1	2	2	2																								2		2																						2																						2		
H5887	007	0	1	01	01	H5887_007_0	5	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
H5887	007	0	1	01	01	H5887_007_0	5	4	4	3	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																						1	2	01000000
H5896	007	0	1	01	01	H5896_007_0	5	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5896	007	0	1	01	01	H5896_007_0	5	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5896	007	0	1	01	01	H5896_007_0	5	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5896	007	0	1	01	01	H5896_007_0	5	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5896	007	0	1	01	01	H5896_007_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	5	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H5896	007	0	1	01	01	H5896_007_0	5	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H5896	007	0	1	01	01	H5896_007_0	5	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H5896	007	0	1	01	01	H5896_007_0	5	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	5	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5896	008	0	1	01	01	H5896_008_0	4	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5896	008	0	1	01	01	H5896_008_0	4	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5896	008	0	1	01	01	H5896_008_0	4	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5896	008	0	1	01	01	H5896_008_0	4	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5896	008	0	1	01	01	H5896_008_0	4	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5896	008	0	1	01	01	H5896_008_0	4	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H5896	008	0	1	01	01	H5896_008_0	4	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H5896	008	0	1	01	01	H5896_008_0	4	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	45.00	135.00	90.00							45.00		45.00	90.00	67.50							45.00			
H5896	008	0	1	01	01	H5896_008_0	4	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	7.00	21.00	14.00							7.00		7.00	14.00	10.50							7.00			
H5896	008	0	1	01	01	H5896_008_0	4	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5896	012	0	1	02	01	H5896_012_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H5896	012	0	1	02	01	H5896_012_0	6	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	10.00	30.00	20.00							10.00		10.00	20.00	15.00							10.00			
H5896	012	0	1	02	01	H5896_012_0	6	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	105.00	70.00							35.00		35.00	70.00	52.50							35.00			
H5896	012	0	1	02	01	H5896_012_0	6	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H5896	012	0	1	02	01	H5896_012_0	6	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H5896	012	0	1	02	01	H5896_012_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H5896	012	0	1	02	01	H5896_012_0	6	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H5896	012	0	1	02	01	H5896_012_0	6	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H5896	012	0	1	02	01	H5896_012_0	6	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H5896	012	0	1	02	01	H5896_012_0	6	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H5918	001	0	1	37	05	H5918_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5918	001	0	1	37	05	H5918_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5918	001	0	1	37	05	H5918_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5918	001	0	1	37	05	H5918_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5918	003	0	1	37	05	H5918_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5918	003	0	1	37	05	H5918_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5918	003	0	1	37	05	H5918_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5918	003	0	1	37	05	H5918_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5918	004	0	1	37	05	H5918_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H5918	004	0	1	37	05	H5918_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H5918	004	0	1	37	05	H5918_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H5918	004	0	1	37	05	H5918_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H5926	001	0	1	01	01	H5926_001_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5926	001	0	1	01	01	H5926_001_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5926	001	0	1	01	01	H5926_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H5926	001	0	1	01	01	H5926_001_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H5926	002	0	1	01	01	H5926_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H5926	002	0	1	01	01	H5926_002_0	4	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H5926	002	0	1	01	01	H5926_002_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H5926	003	0	1	01	01	H5926_003_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	43.00	129.00								43.00			129.00								43.00			
H5926	003	0	1	01	01	H5926_003_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5926	003	0	1	01	01	H5926_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	83.00	249.00								83.00			249.00								83.00			
H5926	003	0	1	01	01	H5926_003_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H5928	002	0	1	01	01	H5928_002_0	8	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	002	0	1	01	01	H5928_002_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	002	0	1	01	01	H5928_002_0	8	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	002	0	1	01	01	H5928_002_0	8	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	002	0	1	01	01	H5928_002_0	8	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	002	0	1	01	01	H5928_002_0	8	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	002	0	1	01	01	H5928_002_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	002	0	1	01	01	H5928_002_0	8	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	002	0	1	01	01	H5928_002_0	8	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	002	0	1	01	01	H5928_002_0	8	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5928	004	0	1	01	01	H5928_004_0	7	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5928	004	0	1	01	01	H5928_004_0	7	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	004	0	1	01	01	H5928_004_0	7	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	004	0	1	01	01	H5928_004_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	004	0	1	01	01	H5928_004_0	7	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	004	0	1	01	01	H5928_004_0	7	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	004	0	1	01	01	H5928_004_0	7	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	004	0	1	01	01	H5928_004_0	7	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	004	0	1	01	01	H5928_004_0	7	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	004	0	1	01	01	H5928_004_0	7	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	006	0	1	01	01	H5928_006_0	4	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5928	006	0	1	01	01	H5928_006_0	4	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	006	0	1	01	01	H5928_006_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	006	0	1	01	01	H5928_006_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	006	0	1	01	01	H5928_006_0	4	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	006	0	1	01	01	H5928_006_0	4	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	006	0	1	01	01	H5928_006_0	4	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	006	0	1	01	01	H5928_006_0	4	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	006	0	1	01	01	H5928_006_0	4	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	006	0	1	01	01	H5928_006_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	008	0	1	01	01	H5928_008_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	008	0	1	01	01	H5928_008_0	5	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	008	0	1	01	01	H5928_008_0	5	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	008	0	1	01	01	H5928_008_0	5	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5928	008	0	1	01	01	H5928_008_0	5	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	008	0	1	01	01	H5928_008_0	5	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	008	0	1	01	01	H5928_008_0	5	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	008	0	1	01	01	H5928_008_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	008	0	1	01	01	H5928_008_0	5	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	008	0	1	01	01	H5928_008_0	5	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	010	0	1	01	01	H5928_010_0	6	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	010	0	1	01	01	H5928_010_0	6	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	010	0	1	01	01	H5928_010_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	010	0	1	01	01	H5928_010_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	010	0	1	01	01	H5928_010_0	6	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	010	0	1	01	01	H5928_010_0	6	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5928	010	0	1	01	01	H5928_010_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	010	0	1	01	01	H5928_010_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	010	0	1	01	01	H5928_010_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	010	0	1	01	01	H5928_010_0	6	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	012	0	1	01	01	H5928_012_0	6	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	012	0	1	01	01	H5928_012_0	6	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	012	0	1	01	01	H5928_012_0	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	012	0	1	01	01	H5928_012_0	6	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	012	0	1	01	01	H5928_012_0	6	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	012	0	1	01	01	H5928_012_0	6	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5928	012	0	1	01	01	H5928_012_0	6	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	012	0	1	01	01	H5928_012_0	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	012	0	1	01	01	H5928_012_0	6	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	012	0	1	01	01	H5928_012_0	6	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	013	0	1	01	01	H5928_013_0	8	5	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H5928	013	0	1	01	01	H5928_013_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H5928	013	0	1	01	01	H5928_013_0	8	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00	1	1	
H5928	013	0	1	01	01	H5928_013_0	8	3	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5928	013	0	1	01	01	H5928_013_0	8	4	4	3	Other Non-Preferred	100100	1	2	1	Other Non-Preferred																								Other Non-Preferred		Other Non-Preferred																						Other Non-Preferred																						2		
H5928	013	0	1	01	01	H5928_013_0	8	5	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5928	013	0	1	01	01	H5928_013_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H5928	013	0	1	01	01	H5928_013_0	8	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	10.00								5.00			10.00								5.00			
H5928	013	0	1	01	01	H5928_013_0	8	3	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	30.00	60.00								30.00			60.00								30.00			
H5928	013	0	1	01	01	H5928_013_0	8	4	4	1	Other Non-Preferred	100100	1	2	1	Other Non-Preferred	111000000010010000000	30	90								30			90								31	1	Other Non-Preferred	2	Other Non-Preferred																						Other Non-Preferred	50.00	100.00								50.00			100.00								50.00			
H5932	001	0	1	01	01	H5932_001_0	3	3	4	1	Tier 3	000010	1	2	1	Tier 3	110000000010000000000	30									30											31		Tier 3	2	Tier 3																						Tier 3	94.75									94.75											94.75			
H5932	001	0	1	01	01	H5932_001_0	3	2	4	1	Tier 2	000010	1	2	2	Tier 2	110000000010000000000	30									30											31		Tier 2	2	Tier 2																						Tier 2	45.00									45.00											45.00			
H5932	001	0	1	01	01	H5932_001_0	3	1	4	1	Tier 1	010000	1	2	2	Tier 1	110000000010000000000	30									30											31		Tier 1	2	Tier 1																						Tier 1	0.00									0.00											0.00			
H5932	001	0	1	01	01	H5932_001_0	3	4	4	1	Tier 4	000010	1	1	2	Tier 4	110000000010000000000	30									30											31		Tier 4	1	Tier 4	25									25											25	Tier 4																								
H5938	001	0	1	01	01	H5938_001_0	8	4	4	1	Specialty Brand/Generic	010010	1	1	2	Specialty Brand/Generic	110000000010000000000	30									30											31		Specialty Brand/Generic	1	Specialty Brand/Generic	10									10											10	Specialty Brand/Generic																								
H5938	001	0	1	01	01	H5938_001_0	8	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00									50.00											50.00			
H5938	001	0	1	01	01	H5938_001_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00									30.00											30.00			
H5938	001	0	1	01	01	H5938_001_0	8	1	4	1	Generic	010000	1	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	15.00									15.00											15.00			
H5938	006	0	1	01	01	H5938_006_0	9	4	4	3	Specialty Brand/Generic	010010	1	1	2	Specialty Brand/Generic																								Specialty Brand/Generic		Specialty Brand/Generic																						Specialty Brand/Generic																						2		
H5938	006	0	1	01	01	H5938_006_0	9	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5938	006	0	1	01	01	H5938_006_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5938	006	0	1	01	01	H5938_006_0	9	1	4	3	Generic	010000	1	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	15.00									15.00											15.00	1	1	
H5938	006	0	1	01	01	H5938_006_0	9	4	4	1	Specialty Brand/Generic	010010	1	1	2	Specialty Brand/Generic	110000000010000000000	30									30											31		Specialty Brand/Generic	1	Specialty Brand/Generic	10									10											10	Specialty Brand/Generic																								
H5938	006	0	1	01	01	H5938_006_0	9	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	110000000010000000000	30									30											31		Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00									50.00											50.00			
H5938	006	0	1	01	01	H5938_006_0	9	1	4	1	Generic	010000	1	2	2	Generic	110000000010000000000	30									30											31		Generic	2	Generic																						Generic	15.00									15.00											15.00			
H5938	006	0	1	01	01	H5938_006_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	110000000010000000000	30									30											31		Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00									30.00											30.00			
H5943	001	0	1	39	05	H5943_001_0	4	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	55.00	165.00								55.00			110.00								55.00			
H5943	001	0	1	39	05	H5943_001_0	4	3	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	30.00	90.00								30.00			60.00								30.00			
H5943	001	0	1	39	05	H5943_001_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	6.00	18.00								6.00			12.00								6.00			
H5943	001	0	1	39	05	H5943_001_0	4	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H5943	001	0	1	39	05	H5943_001_0	4	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H5948	001	0	1	01	01	H5948_001_0	6	3	4	1	Tier 3	000010	1	2	2	Tier 3	111000000001010000000	30	90									10		90								31	2	Tier 3	2	Tier 3																						Tier 3	50.00	150.00									50.00		100.00								50.00			
H5948	001	0	1	01	01	H5948_001_0	6	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000001010000000	30	90									10		90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00		0.00								0.00	1	1	
H5948	001	0	1	01	01	H5948_001_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									10		90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00									15.00		30.00								15.00			
H5948	001	0	1	01	01	H5948_001_0	6	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000001010000000	30	90									10		90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00		0.00								0.00			
H5948	001	0	1	01	01	H5948_001_0	6	4	4	3	Tier 4	010011	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H5948	001	0	1	01	01	H5948_001_0	6	3	4	3	Tier 3	000010	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H5948	001	0	1	01	01	H5948_001_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									10		90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00									15.00		30.00								15.00	1	1	
H5948	001	0	1	01	01	H5948_001_0	6	4	4	1	Tier 4	010011	1	1	1	Tier 4	111000000001010000000	30	90									10		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H5950	001	0	1	01	01	H5950_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	9.00	27.00									9.00					18.00			27.00		9.00			
H5950	001	0	1	01	01	H5950_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					56.00			84.00		28.00			
H5950	001	0	1	01	01	H5950_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H5950	001	0	1	01	01	H5950_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	74.00	222.00									74.00					148.00			222.00		74.00			
H5950	001	0	1	01	01	H5950_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					58.00			87.00		29.00			
H5969	001	0	1	01	01	H5969_001_0	6	1	4	1	Generic	011100	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	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	4	4	1	Specialty	100011	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5969	001	0	1	01	01	H5969_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00		65.00	130.00								65.00			
H5969	001	0	1	01	01	H5969_001_0	6	2	4	1	Preferred Brand	000011	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H5970	001	0	1	04	01	H5970_001_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5970	001	0	1	04	01	H5970_001_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5970	001	0	1	04	01	H5970_001_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5970	001	0	1	04	01	H5970_001_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5970	001	0	1	04	01	H5970_001_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5970	001	0	1	04	01	H5970_001_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5970	001	0	1	04	01	H5970_001_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5970	001	0	1	04	01	H5970_001_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5970	002	0	1	04	01	H5970_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H5970	002	0	1	04	01	H5970_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H5970	002	0	1	04	01	H5970_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H5970	002	0	1	04	01	H5970_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H5970	002	0	1	04	01	H5970_002_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H5970	002	0	1	04	01	H5970_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H5970	002	0	1	04	01	H5970_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H5970	002	0	1	04	01	H5970_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H5980	006	0	1	01	01	H5980_006_0	18	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									30.00		60.00								30.00			
H5980	006	0	1	01	01	H5980_006_0	18	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	31	90									29		90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	130.00									65.00		130.00								65.00			
H5980	006	0	1	01	01	H5980_006_0	18	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001100000000	31	90									29	31									31	1	Specialty	1	Specialty	33	33									33	33									33	Specialty																								
H5980	006	0	1	01	01	H5980_006_0	18	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5980	006	0	1	01	01	H5980_006_0	18	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H5980	006	0	1	01	01	H5980_006_0	18	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5980	006	0	1	01	01	H5980_006_0	18	1	4	3	generic	010000	1	2	2	generic	111000000001010000000	31	90									29		90								31	1	generic	2	generic																						generic	5.00	10.00									5.00		10.00								5.00	1	1	
H5980	006	0	1	01	01	H5980_006_0	18	1	4	1	generic	010000	1	2	2	generic	111000000001010000000	31	90									29		90								31	1	generic	2	generic																						generic	5.00	10.00									5.00		10.00								5.00			
H5980	007	0	1	01	01	H5980_007_0	18	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H5980	007	0	1	01	01	H5980_007_0	18	3	4	3	Non-Preferred	100000	1	2	2	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
H5980	007	0	1	01	01	H5980_007_0	18	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5980	007	0	1	01	01	H5980_007_0	18	1	4	3	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00	1	1	
H5980	007	0	1	01	01	H5980_007_0	18	4	4	1	Specialty	000010	1	1	1	Specialty	111000000001010000000	31	90									29		90								31	1	Specialty	1	Specialty	33	33									33		33								33	Specialty																								
H5980	007	0	1	01	01	H5980_007_0	18	3	4	1	Non-Preferred	100000	1	2	2	Non-Preferred	111000000001010000000	31	90									29		90								31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	65.00	130.00									65.00		130.00								65.00			
H5980	007	0	1	01	01	H5980_007_0	18	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	31	90									29		90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00		10.00								5.00			
H5980	007	0	1	01	01	H5980_007_0	18	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	31	90									29		90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00									30.00		60.00								30.00			
H5985	001	0	1	01	01	H5985_001_0	5	3	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H5985	001	0	1	01	01	H5985_001_0	5	4	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H5985	001	0	1	01	01	H5985_001_0	5	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H5985	001	0	1	01	01	H5985_001_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	30.00								10.00	1	1	
H5985	001	0	1	01	01	H5985_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	30.00								10.00			
H5985	001	0	1	01	01	H5985_001_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	120.00								40.00			
H5985	001	0	1	01	01	H5985_001_0	5	3	4	1	Brand	000010	1	2	2	Brand	111000000010110000000	30	90								30		30	90								31	1	Brand	2	Brand																						Brand	40.00	120.00								40.00		40.00	120.00								40.00			
H5985	001	0	1	01	01	H5985_001_0	5	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	20	20								20		20	20								20	Specialty																								
H5989	004	0	1	01	01	H5989_004_0	10	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5989	004	0	1	01	01	H5989_004_0	10	2	4	1	Preferred Brand	000011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	10	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00		60.00	180.00								60.00			
H5989	004	0	1	01	01	H5989_004_0	10	4	4	1	Specialty	100011	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H5992	005	0	1	01	01	H5992_005_0	4	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010110000000	34	93								34		34	93								34	2	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H5992	005	0	1	01	01	H5992_005_0	4	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010110000000	34	93								34		34	93								34	2	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	45.00	135.00								45.00		45.00	135.00								45.00			
H5992	005	0	1	01	01	H5992_005_0	4	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010110000000	34	93								34		34	93								34	2	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	64.00	192.00								64.00		64.00	192.00								64.00			
H5995	002	0	1	01	01	H5995_002_0	4	1	4	1	Tier 1 - Generics	010000	1	2	2	Tier 1 - Generics	111000000001110000000	30	90									29	30	90								31	2	Tier 1 - Generics	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	2	4	1	Tier 2 - Brand	000010	1	2	1	Tier 2 - Brand	111000000001110000000	30	90									29	30	90								31	2	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	20.00	60.00									20.00	20.00	60.00								20.00			
H5995	002	0	1	01	01	H5995_002_0	4	3	4	1	Tier 3 - Specialty	010010	1	1	2	Tier 3 - Specialty	111000000001110000000	30	90									29	30	90								31	2	Tier 3 - Specialty	1	Tier 3 - Specialty	25	25									25	25	25								25	Tier 3 - Specialty																								
H6120	002	0	1	01	01	H6120_002_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H6120	002	0	1	01	01	H6120_002_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H6120	002	0	1	01	01	H6120_002_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H6120	002	0	1	01	01	H6120_002_0	4	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H6120	002	0	1	01	01	H6120_002_0	4	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H6120	002	0	1	01	01	H6120_002_0	4	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H6120	002	0	1	01	01	H6120_002_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H6120	002	0	1	01	01	H6120_002_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H6120	003	0	1	01	01	H6120_003_0	5	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H6120	003	0	1	01	01	H6120_003_0	5	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H6120	003	0	1	01	01	H6120_003_0	5	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H6120	003	0	1	01	01	H6120_003_0	5	2	4	3	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00	1	1	
H6120	003	0	1	01	01	H6120_003_0	5	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H6120	003	0	1	01	01	H6120_003_0	5	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H6120	003	0	1	01	01	H6120_003_0	5	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H6120	003	0	1	01	01	H6120_003_0	5	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00								15.00			30.00								15.00			
H6178	001	0	1	01	01	H6178_001_0	9	1	4	1	Tier 1	011000	1	2	2	Tier 1	111000000010010000000	34	90								34			90								34	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H6178	001	0	1	01	01	H6178_001_0	9	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	34	90								34			90								34	2	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			135.00								45.00			
H6178	001	0	1	01	01	H6178_001_0	9	3	4	1	Tier 3	010010	1	1	2	Tier 3	111000000010010000000	34	90								34			90								34	2	Tier 3	1	Tier 3	25	25								25			25								25	Tier 3																								
H6178	001	0	1	01	01	H6178_001_0	9	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010010000000	34	90								34			90								34	2	Tier 4	2	Tier 4																						Tier 4	98.00	294.00								98.00			294.00								98.00			
H6181	007	0	1	01	01	H6181_007_0	4	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H6181	007	0	1	01	01	H6181_007_0	4	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H6181	007	0	1	01	01	H6181_007_0	4	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H6181	007	0	1	01	01	H6181_007_0	4	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H6181	007	0	1	01	01	H6181_007_0	4	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H6181	007	0	1	01	01	H6181_007_0	4	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H6181	007	0	1	01	01	H6181_007_0	4	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H6181	007	0	1	01	01	H6181_007_0	4	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H6181	007	0	1	01	01	H6181_007_0	4	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	4	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6181	008	0	1	01	01	H6181_008_0	3	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H6181	008	0	1	01	01	H6181_008_0	3	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H6181	008	0	1	01	01	H6181_008_0	3	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H6181	008	0	1	01	01	H6181_008_0	3	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H6181	008	0	1	01	01	H6181_008_0	3	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H6181	008	0	1	01	01	H6181_008_0	3	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H6181	008	0	1	01	01	H6181_008_0	3	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	20.00	60.00	40.00							20.00		20.00	40.00	30.00							20.00			
H6181	008	0	1	01	01	H6181_008_0	3	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	3.00	9.00	6.00							3.00		3.00	6.00	4.50							3.00			
H6181	008	0	1	01	01	H6181_008_0	3	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6181	008	0	1	01	01	H6181_008_0	3	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H6181	009	0	1	01	01	H6181_009_0	6	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H6181	009	0	1	01	01	H6181_009_0	6	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H6181	009	0	1	01	01	H6181_009_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6181	009	0	1	01	01	H6181_009_0	6	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	3.00	9.00	6.00							3.00		3.00	6.00	4.50							3.00			
H6181	009	0	1	01	01	H6181_009_0	6	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	20.00	60.00	40.00							20.00		20.00	40.00	30.00							20.00			
H6181	009	0	1	01	01	H6181_009_0	6	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H6181	009	0	1	01	01	H6181_009_0	6	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H6181	009	0	1	01	01	H6181_009_0	6	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H6181	009	0	1	01	01	H6181_009_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H6181	009	0	1	01	01	H6181_009_0	6	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	3.00	9.00	6.00							3.00		3.00	6.00	4.50							3.00	1	1	
H6228	001	0	1	37	05	H6228_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H6228	001	0	1	37	05	H6228_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H6228	001	0	1	37	05	H6228_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H6228	001	0	1	37	05	H6228_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H6228	003	0	1	37	05	H6228_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H6228	003	0	1	37	05	H6228_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H6228	003	0	1	37	05	H6228_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H6228	003	0	1	37	05	H6228_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H6328	001	0	1	04	01	H6328_001_0	9	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H6328	001	0	1	04	01	H6328_001_0	9	3	4	3	Non- Preferred Drugs	100100	1	2	1	Non- Preferred Drugs																								Non- Preferred Drugs		Non- Preferred Drugs																						Non- Preferred Drugs																						2		
H6328	001	0	1	04	01	H6328_001_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H6328	001	0	1	04	01	H6328_001_0	9	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	100011011001110000000				30	90		30	90			29	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00	0.00		4.00	12.00			4.00	4.00	12.00								4.00	1	1	
H6328	001	0	1	04	01	H6328_001_0	9	4	4	1	Specialty	010010	1	1	2	Specialty	100011011001110000000				30	90		30	90			29	30	90								31	2	Specialty	1	Specialty				33	33		33	33			33	33	33								33	Specialty																								
H6328	001	0	1	04	01	H6328_001_0	9	3	4	1	Non- Preferred Drugs	100100	1	2	1	Non- Preferred Drugs	100011011001110000000				30	90		30	90			29	30	90								31	2	Non- Preferred Drugs	2	Non- Preferred Drugs																						Non- Preferred Drugs				60.00	180.00		60.00	180.00			60.00	60.00	180.00								60.00			
H6328	001	0	1	04	01	H6328_001_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011001110000000				30	90		30	90			29	30	90								31	2	Preferred Brand	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	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	100011011001110000000				30	90		30	90			29	30	90								31	1	Preferred Generic	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	1	Non- Preferred Drugs																								Non- Preferred Drugs		Non- Preferred Drugs																						Non- Preferred Drugs																						2		
H6328	002	0	1	04	01	H6328_002_0	8	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
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																						2		
H6328	002	0	1	04	01	H6328_002_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	100011011001110000000				30	90		30	90			29	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00	0.00		5.00	15.00			5.00	5.00	15.00								5.00	1	1	
H6328	002	0	1	04	01	H6328_002_0	8	4	4	1	Specialty	010010	1	1	2	Specialty	100011011001110000000				30	90		30	90			29	30	90								31	2	Specialty	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	1	Non- Preferred Drugs	100011011001110000000				30	90		30	90			29	30	90								31	2	Non- Preferred Drugs	2	Non- Preferred Drugs																						Non- Preferred Drugs				65.00	195.00		65.00	195.00			65.00	65.00	195.00								65.00			
H6328	002	0	1	04	01	H6328_002_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011001110000000				30	90		30	90			29	30	90								31	2	Preferred Brand	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	2	Preferred Generic	100011011001110000000				30	90		30	90			29	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				0.00	0.00		5.00	15.00			5.00	5.00	15.00								5.00			
H6328	003	0	1	04	01	H6328_003_0	8	3	4	3	Non- Preferred Drugs	100100	1	2	1	Non- Preferred Drugs																								Non- Preferred Drugs		Non- Preferred Drugs																						Non- Preferred Drugs																						2		
H6328	003	0	1	04	01	H6328_003_0	8	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H6328	003	0	1	04	01	H6328_003_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	100011011001110000000				30	90		30	90			29	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				2.00	6.00		5.00	15.00			5.00	5.00	15.00								5.00	1	1	
H6328	003	0	1	04	01	H6328_003_0	8	4	4	1	Specialty	010010	1	1	2	Specialty	100011011001110000000				30	90		30	90			29	30	90								31	2	Specialty	1	Specialty				33	33		33	33			33	33	33								33	Specialty																								
H6328	003	0	1	04	01	H6328_003_0	8	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H6328	003	0	1	04	01	H6328_003_0	8	3	4	1	Non- Preferred Drugs	100100	1	2	1	Non- Preferred Drugs	100011011001110000000				30	90		30	90			29	30	90								31	2	Non- Preferred Drugs	2	Non- Preferred Drugs																						Non- Preferred Drugs				65.00	195.00		65.00	195.00			65.00	65.00	195.00								65.00			
H6328	003	0	1	04	01	H6328_003_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	100011011001110000000				30	90		30	90			29	30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				2.00	6.00		5.00	15.00			5.00	5.00	15.00								5.00			
H6328	003	0	1	04	01	H6328_003_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011001110000000				30	90		30	90			29	30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand				35.00	105.00		35.00	105.00			35.00	35.00	105.00								35.00			
H6360	001	0	1	18	06	H6360_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00			
H6360	001	0	1	18	06	H6360_001_0	4	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	31	90								31		31	90								31	1	Brand	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H6360	001	0	1	18	06	H6360_001_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00	1	1	
H6360	001	0	1	18	06	H6360_001_0	4	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	31	90								31		31	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H6360	001	0	1	18	06	H6360_001_0	4	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H6360	001	0	1	18	06	H6360_001_0	4	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H6360	002	0	1	18	06	H6360_002_0	3	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H6360	002	0	1	18	06	H6360_002_0	3	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H6360	002	0	1	18	06	H6360_002_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H6360	002	0	1	18	06	H6360_002_0	3	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	31	90								31		31	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H6360	002	0	1	18	06	H6360_002_0	3	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	31	90								31		31	90								31	1	Brand	2	Brand																						Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H6360	002	0	1	18	06	H6360_002_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H6360	006	0	1	18	06	H6360_006_0	3	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	31	90								31		31	90								31	1	Brand	2	Brand																						Brand	46.00	138.00								46.00		46.00	92.00								46.00			
H6360	006	0	1	18	06	H6360_006_0	3	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	31	90								31		31	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H6360	006	0	1	18	06	H6360_006_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	12.00	36.00								12.00		12.00	24.00								12.00			
H6360	009	0	2	18	06	H6360_009_0	3	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	31	90								31		31	90								31	1	Brand	2	Brand																						Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H6360	009	0	2	18	06	H6360_009_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00	1	1	
H6360	009	0	2	18	06	H6360_009_0	3	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H6360	009	0	2	18	06	H6360_009_0	3	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H6360	009	0	2	18	06	H6360_009_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	1	Generic	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00			
H6360	009	0	2	18	06	H6360_009_0	3	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	31	90								31		31	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H6411	002	0	1	04	01	H6411_002_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H6411	002	0	1	04	01	H6411_002_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H6411	002	0	1	04	01	H6411_002_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H6411	002	0	1	04	01	H6411_002_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6411	002	0	1	04	01	H6411_002_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H6411	002	0	1	04	01	H6411_002_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6411	002	0	1	04	01	H6411_002_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H6411	002	0	1	04	01	H6411_002_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6411	007	0	1	04	01	H6411_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00	1	2	10000000
H6411	007	0	1	04	01	H6411_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6411	007	0	1	04	01	H6411_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6411	007	0	1	04	01	H6411_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H6411	007	0	1	04	01	H6411_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H6411	007	0	1	04	01	H6411_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H6411	007	0	1	04	01	H6411_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00					75.00	187.50		75.00	225.00		75.00			
H6411	007	0	1	04	01	H6411_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6421	012	0	1	09	04	H6421_012_0	4	4	3	1	Specialty	010010		1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H6421	012	0	1	09	04	H6421_012_0	4	3	3	1	Non-Preferred Brand	110010		2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	4	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H6421	012	0	1	09	04	H6421_012_0	4	1	3	1	Generic	010000		2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	8.50	25.50								8.50		8.50	17.00								8.50			
H6528	001	0	1	04	01	H6528_001_0	4	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
H6528	001	0	1	04	01	H6528_001_0	4	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
H6528	001	0	1	04	01	H6528_001_0	4	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
H6528	001	0	1	04	01	H6528_001_0	4	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	90.00								36.00			
H6609	001	0	1	04	01	H6609_001_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	001	0	1	04	01	H6609_001_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6609	001	0	1	04	01	H6609_001_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	001	0	1	04	01	H6609_001_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	001	0	1	04	01	H6609_001_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H6609	001	0	1	04	01	H6609_001_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	001	0	1	04	01	H6609_001_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	001	0	1	04	01	H6609_001_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	003	0	1	04	01	H6609_003_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H6609	003	0	1	04	01	H6609_003_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	003	0	1	04	01	H6609_003_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6609	003	0	1	04	01	H6609_003_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H6609	003	0	1	04	01	H6609_003_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	003	0	1	04	01	H6609_003_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	003	0	1	04	01	H6609_003_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H6609	003	0	1	04	01	H6609_003_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	005	0	1	04	01	H6609_005_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	005	0	1	04	01	H6609_005_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H6609	005	0	1	04	01	H6609_005_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00	1	2	00001000
H6609	005	0	1	04	01	H6609_005_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	005	0	1	04	01	H6609_005_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	005	0	1	04	01	H6609_005_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	005	0	1	04	01	H6609_005_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00					0.00	0.00		9.00	27.00		9.00			
H6609	005	0	1	04	01	H6609_005_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	007	0	1	04	01	H6609_007_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H6609	007	0	1	04	01	H6609_007_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	007	0	1	04	01	H6609_007_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	007	0	1	04	01	H6609_007_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	007	0	1	04	01	H6609_007_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H6609	007	0	1	04	01	H6609_007_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H6609	007	0	1	04	01	H6609_007_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	007	0	1	04	01	H6609_007_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	009	0	1	04	01	H6609_009_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	009	0	1	04	01	H6609_009_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	009	0	1	04	01	H6609_009_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10000000
H6609	009	0	1	04	01	H6609_009_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	009	0	1	04	01	H6609_009_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	009	0	1	04	01	H6609_009_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	009	0	1	04	01	H6609_009_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	009	0	1	04	01	H6609_009_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	010	0	1	04	01	H6609_010_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	010	0	1	04	01	H6609_010_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	010	0	1	04	01	H6609_010_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10000000
H6609	010	0	1	04	01	H6609_010_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	010	0	1	04	01	H6609_010_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	010	0	1	04	01	H6609_010_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	010	0	1	04	01	H6609_010_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	010	0	1	04	01	H6609_010_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	011	0	1	04	01	H6609_011_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	011	0	1	04	01	H6609_011_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	011	0	1	04	01	H6609_011_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	011	0	1	04	01	H6609_011_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	011	0	1	04	01	H6609_011_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	011	0	1	04	01	H6609_011_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10000000
H6609	011	0	1	04	01	H6609_011_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	011	0	1	04	01	H6609_011_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	013	0	1	04	01	H6609_013_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	013	0	1	04	01	H6609_013_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	013	0	1	04	01	H6609_013_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	013	0	1	04	01	H6609_013_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	013	0	1	04	01	H6609_013_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	013	0	1	04	01	H6609_013_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	013	0	1	04	01	H6609_013_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	013	0	1	04	01	H6609_013_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H6609	014	0	1	04	01	H6609_014_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	014	0	1	04	01	H6609_014_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	014	0	1	04	01	H6609_014_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	014	0	1	04	01	H6609_014_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	014	0	1	04	01	H6609_014_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H6609	014	0	1	04	01	H6609_014_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	014	0	1	04	01	H6609_014_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	014	0	1	04	01	H6609_014_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	015	0	1	04	01	H6609_015_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	015	0	1	04	01	H6609_015_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H6609	015	0	1	04	01	H6609_015_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	015	0	1	04	01	H6609_015_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	015	0	1	04	01	H6609_015_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	015	0	1	04	01	H6609_015_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6609	015	0	1	04	01	H6609_015_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	015	0	1	04	01	H6609_015_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	016	0	1	04	01	H6609_016_0	5	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6609	016	0	1	04	01	H6609_016_0	5	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6609	016	0	1	04	01	H6609_016_0	5	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H6609	016	0	1	04	01	H6609_016_0	5	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	2	00001000
H6609	016	0	1	04	01	H6609_016_0	5	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6609	016	0	1	04	01	H6609_016_0	5	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6609	016	0	1	04	01	H6609_016_0	5	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H6609	016	0	1	04	01	H6609_016_0	5	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H6642	001	0	1	02	01	H6642_001_0	3	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H6642	001	0	1	02	01	H6642_001_0	3	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6642	001	0	1	02	01	H6642_001_0	3	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H6642	001	0	1	02	01	H6642_001_0	3	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H6642	001	0	1	02	01	H6642_001_0	3	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00		25.00	50.00	50.00							25.00			
H6642	002	0	1	02	01	H6642_002_0	3	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H6642	002	0	1	02	01	H6642_002_0	3	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6642	002	0	1	02	01	H6642_002_0	3	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H6642	002	0	1	02	01	H6642_002_0	3	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H6642	002	0	1	02	01	H6642_002_0	3	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00		25.00	50.00	50.00							25.00			
H6642	003	0	1	02	01	H6642_003_0	3	1	4	1	Value Generic	011000	1	2	2	Value Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Value Generic	2	Value Generic																						Value Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6642	003	0	1	02	01	H6642_003_0	3	4	4	1	Non Preferred Brand	110010	1	2	1	Non Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	60.00	180.00	120.00							60.00		60.00	120.00	120.00							60.00			
H6642	003	0	1	02	01	H6642_003_0	3	3	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00	50.00							25.00		25.00	50.00	50.00							25.00			
H6642	003	0	1	02	01	H6642_003_0	3	2	4	1	Generic	010100	1	2	2	Generic	111100000010111000000	31	90	60							31		31	90	60							34	2	Generic	2	Generic																						Generic	5.00	15.00	10.00							5.00		5.00	10.00	10.00							5.00			
H6642	003	0	1	02	01	H6642_003_0	3	5	4	1	Speciality	010010	1	1	2	Speciality	111100000010111000000	31	90	60							31		31	90	60							34	2	Speciality	1	Speciality	33	33	33							33		33	33	33							33	Speciality																								
H6793	001	0	1	37	05	H6793_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H6793	001	0	1	37	05	H6793_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H6793	001	0	1	37	05	H6793_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H6793	001	0	1	37	05	H6793_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H6793	003	0	1	37	05	H6793_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H6793	003	0	1	37	05	H6793_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	37.00	111.00								37.00						101.00			111.00		37.00			
H6793	003	0	1	37	05	H6793_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						215.00			225.00		75.00			
H6793	003	0	1	37	05	H6793_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H6864	001	0	1	02	01	H6864_001_0	7	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H6864	001	0	1	02	01	H6864_001_0	7	4	3	1	Specialty	111111		1	2	Specialty	111100000010111000000	30	90	60							30		30	90	60							31	1	Specialty	1	Specialty	25	25	25							25		25	25	25							25	Specialty																								
H6864	001	0	1	02	01	H6864_001_0	7	3	3	1	Non-Preferred	110110		2	1	Non-Preferred	111100000010111000000	30	90	60							30		30	90	60							31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	95.00	285.00	190.00							95.00		95.00	285.00	190.00							95.00			
H6864	001	0	1	02	01	H6864_001_0	7	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00	60.00							30.00		30.00	90.00	60.00							30.00			
H6900	001	0	1	04	01	H6900_001_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6900	001	0	1	04	01	H6900_001_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6900	001	0	1	04	01	H6900_001_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6900	001	0	1	04	01	H6900_001_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H6900	001	0	1	04	01	H6900_001_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6900	001	0	1	04	01	H6900_001_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6900	001	0	1	04	01	H6900_001_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H6900	002	0	1	04	01	H6900_002_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6900	002	0	1	04	01	H6900_002_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6900	002	0	1	04	01	H6900_002_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6900	002	0	1	04	01	H6900_002_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6900	002	0	1	04	01	H6900_002_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6900	004	0	1	04	01	H6900_004_0	9	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H6900	004	0	1	04	01	H6900_004_0	9	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H6900	004	0	1	04	01	H6900_004_0	9	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H6900	004	0	1	04	01	H6900_004_0	9	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H6900	004	0	1	04	01	H6900_004_0	9	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H6900	004	0	1	04	01	H6900_004_0	9	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H6900	004	0	1	04	01	H6900_004_0	9	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H6900	004	0	1	04	01	H6900_004_0	9	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H6923	001	0	1	01	01	H6923_001_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H6923	001	0	1	01	01	H6923_001_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	34.00	102.00									34.00					68.00			102.00		34.00			
H6923	001	0	1	01	01	H6923_001_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H6923	001	0	1	01	01	H6923_001_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					72.00			108.00		36.00			
H6923	001	0	1	01	01	H6923_001_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					12.00			18.00		6.00			
H6923	003	0	1	01	01	H6923_003_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					70.00			105.00		35.00			
H6923	003	0	1	01	01	H6923_003_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H6923	003	0	1	01	01	H6923_003_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					160.00			240.00		80.00			
H6923	003	0	1	01	01	H6923_003_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	30.00	90.00									30.00					60.00			90.00		30.00			
H6923	003	0	1	01	01	H6923_003_0	4	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					14.00			21.00		7.00			
H7002	002	0	1	04	01	H7002_002_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H7002	002	0	1	04	01	H7002_002_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H7002	002	0	1	04	01	H7002_002_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H7002	002	0	1	04	01	H7002_002_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H7002	002	0	1	04	01	H7002_002_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H7002	002	0	1	04	01	H7002_002_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H7002	002	0	1	04	01	H7002_002_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H7002	002	0	1	04	01	H7002_002_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H7006	001	0	1	04	01	H7006_001_0	5	3	4	1	Tier 3 - Specialty	010010	1	1	2	Tier 3 - Specialty	111000000001110000000	30	90									29	30	90								31	2	Tier 3 - Specialty	1	Tier 3 - Specialty	25	25									25	25	25								25	Tier 3 - Specialty																								
H7006	001	0	1	04	01	H7006_001_0	5	1	4	1	Tier 1 - Generics	010000	1	2	2	Tier 1 - Generics	111000000001110000000	30	90									29	30	90								31	2	Tier 1 - Generics	2	Tier 1 - Generics																						Tier 1 - Generics	5.00	15.00									5.00	5.00	15.00								5.00			
H7006	001	0	1	04	01	H7006_001_0	5	2	4	1	Tier 2 - Brand	000010	1	2	1	Tier 2 - Brand	111000000001110000000	30	90									29	30	90								31	2	Tier 2 - Brand	2	Tier 2 - Brand																						Tier 2 - Brand	20.00	60.00									20.00	20.00	60.00								20.00			
H7015	001	0	1	01	01	H7015_001_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			12.50								5.00			
H7015	001	0	1	01	01	H7015_001_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	7	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00			
H7015	001	0	1	01	01	H7015_001_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
H7086	001	0	1	01	01	H7086_001_0	3	1	4	1	Generic	011100	1	2	2	Generic	111000000010010000000	31	93								31			93								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H7086	001	0	1	01	01	H7086_001_0	3	2	4	1	Brand	100011	1	2	1	Brand	111000000010010000000	31	93								31			93								31	1	Brand	2	Brand																						Brand	47.00	94.00								47.00			94.00								47.00			
H7149	001	0	1	01	01	H7149_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H7149	001	0	1	01	01	H7149_001_0	7	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H7149	001	0	1	01	01	H7149_001_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H7149	001	0	1	01	01	H7149_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H7179	001	0	1	01	01	H7179_001_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	001	0	1	01	01	H7179_001_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H7179	001	0	1	01	01	H7179_001_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	001	0	1	01	01	H7179_001_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H7179	001	0	1	01	01	H7179_001_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H7179	001	0	1	01	01	H7179_001_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H7179	001	0	1	01	01	H7179_001_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7179	001	0	1	01	01	H7179_001_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	001	0	1	01	01	H7179_001_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H7179	001	0	1	01	01	H7179_001_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																						2		
H7179	002	0	1	01	01	H7179_002_0	6	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	002	0	1	01	01	H7179_002_0	6	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H7179	002	0	1	01	01	H7179_002_0	6	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H7179	002	0	1	01	01	H7179_002_0	6	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H7179	002	0	1	01	01	H7179_002_0	6	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7179	002	0	1	01	01	H7179_002_0	6	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	002	0	1	01	01	H7179_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																						2		
H7179	002	0	1	01	01	H7179_002_0	6	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H7179	002	0	1	01	01	H7179_002_0	6	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	002	0	1	01	01	H7179_002_0	6	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H7179	007	0	1	01	01	H7179_007_0	5	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	007	0	1	01	01	H7179_007_0	5	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H7179	007	0	1	01	01	H7179_007_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																						2		
H7179	007	0	1	01	01	H7179_007_0	5	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H7179	007	0	1	01	01	H7179_007_0	5	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	007	0	1	01	01	H7179_007_0	5	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7179	007	0	1	01	01	H7179_007_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H7179	007	0	1	01	01	H7179_007_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H7179	007	0	1	01	01	H7179_007_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H7179	007	0	1	01	01	H7179_007_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	009	0	1	02	01	H7179_009_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00	1	1	
H7179	009	0	1	02	01	H7179_009_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00			
H7179	009	0	1	02	01	H7179_009_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	12.00	36.00								12.00			24.00								12.00			
H7179	009	0	1	02	01	H7179_009_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	44.00	132.00								44.00			88.00								44.00			
H7179	009	0	1	02	01	H7179_009_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	79.00	237.00								79.00			158.00								79.00			
H7179	009	0	1	02	01	H7179_009_0	8	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7179	009	0	1	02	01	H7179_009_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00								3.00			6.00								3.00	1	1	
H7179	009	0	1	02	01	H7179_009_0	8	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H7179	009	0	1	02	01	H7179_009_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	009	0	1	02	01	H7179_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																						2		
H7179	010	0	1	01	01	H7179_010_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																						2		
H7179	010	0	1	01	01	H7179_010_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	010	0	1	01	01	H7179_010_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Speciality																								Tier 5 - Speciality		Tier 5 - Speciality																						Tier 5 - Speciality																						2		
H7179	010	0	1	01	01	H7179_010_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	010	0	1	01	01	H7179_010_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H7179	010	0	1	01	01	H7179_010_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	107.00								39.00			78.00								39.00			
H7179	010	0	1	01	01	H7179_010_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H7179	010	0	1	01	01	H7179_010_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7179	010	0	1	01	01	H7179_010_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	010	0	1	01	01	H7179_010_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H7179	011	0	1	01	01	H7179_011_0	8	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H7179	011	0	1	01	01	H7179_011_0	8	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	011	0	1	01	01	H7179_011_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																						2		
H7179	011	0	1	01	01	H7179_011_0	8	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H7179	011	0	1	01	01	H7179_011_0	8	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	011	0	1	01	01	H7179_011_0	8	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7179	011	0	1	01	01	H7179_011_0	8	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H7179	011	0	1	01	01	H7179_011_0	8	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H7179	011	0	1	01	01	H7179_011_0	8	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	011	0	1	01	01	H7179_011_0	8	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	5.00	15.00								5.00			10.00								5.00			
H7179	012	0	1	01	01	H7179_012_0	7	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
H7179	012	0	1	01	01	H7179_012_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																						2		
H7179	012	0	1	01	01	H7179_012_0	7	2	4	3	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	012	0	1	01	01	H7179_012_0	7	1	4	3	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7179	012	0	1	01	01	H7179_012_0	7	5	4	3	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
H7179	012	0	1	01	01	H7179_012_0	7	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00								69.00			138.00								69.00			
H7179	012	0	1	01	01	H7179_012_0	7	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	39.00	117.00								39.00			78.00								39.00			
H7179	012	0	1	01	01	H7179_012_0	7	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	012	0	1	01	01	H7179_012_0	7	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7179	012	0	1	01	01	H7179_012_0	7	5	4	1	Tier 5 - Specialty	000010	1	1	2	Tier 5 - Specialty	111000000010010000000	30	90								30			90								31	2	Tier 5 - Specialty	4	Tier 5 - Specialty	33	33								33			33								33	Tier 5 - Specialty	300.00	900.00								300.00			900.00								300.00			
H7187	003	0	1	02	01	H7187_003_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H7187	003	0	1	02	01	H7187_003_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H7187	003	0	1	02	01	H7187_003_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H7187	003	0	1	02	01	H7187_003_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						0.00			18.00		6.00			
H7187	008	0	1	02	01	H7187_008_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
H7187	008	0	1	02	01	H7187_008_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H7187	008	0	1	02	01	H7187_008_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
H7187	008	0	1	02	01	H7187_008_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H7187	009	0	1	02	01	H7187_009_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H7187	009	0	1	02	01	H7187_009_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						0.00			15.00		5.00			
H7187	009	0	1	02	01	H7187_009_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H7187	009	0	1	02	01	H7187_009_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H7188	003	0	1	04	01	H7188_003_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H7188	003	0	1	04	01	H7188_003_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H7188	003	0	1	04	01	H7188_003_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H7188	003	0	1	04	01	H7188_003_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H7188	003	0	1	04	01	H7188_003_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H7188	003	0	1	04	01	H7188_003_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H7188	003	0	1	04	01	H7188_003_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H7188	003	0	1	04	01	H7188_003_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H7200	006	0	1	01	01	H7200_006_0	5	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	5	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H7200	006	0	1	01	01	H7200_006_0	5	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H7200	006	0	1	01	01	H7200_006_0	5	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H7200	006	0	1	01	01	H7200_006_0	5	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H7200	006	0	1	01	01	H7200_006_0	5	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	5	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H7200	006	0	1	01	01	H7200_006_0	5	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H7200	006	0	1	01	01	H7200_006_0	5	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H7200	006	0	1	01	01	H7200_006_0	5	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H7200	007	0	1	01	01	H7200_007_0	6	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H7200	007	0	1	01	01	H7200_007_0	6	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H7200	007	0	1	01	01	H7200_007_0	6	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H7200	007	0	1	01	01	H7200_007_0	6	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H7200	007	0	1	01	01	H7200_007_0	6	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H7200	007	0	1	01	01	H7200_007_0	6	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00			
H7200	007	0	1	01	01	H7200_007_0	6	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	3.00	9.00	6.00							3.00		3.00	6.00	4.50							3.00			
H7200	007	0	1	01	01	H7200_007_0	6	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	30.00	90.00	60.00							30.00		30.00	60.00	45.00							30.00			
H7200	007	0	1	01	01	H7200_007_0	6	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	60.00	180.00	120.00							60.00		60.00	120.00	90.00							60.00			
H7200	007	0	1	01	01	H7200_007_0	6	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H7220	003	0	1	01	01	H7220_003_0	6	4	4	1	Specialty	111111	1	1	1	Specialty	110000000001100000000	31										29	31									31		Specialty	1	Specialty	30										30	30									30	Specialty																								
H7220	003	0	1	01	01	H7220_003_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001110000000	31	90									29	31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50									35.00	35.00	87.50								35.00			
H7220	003	0	1	01	01	H7220_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	90									29	31	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00									70.00	70.00	175.00								70.00			
H7220	003	0	1	01	01	H7220_003_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	31	90									29	31	90								31	1	Generic	2	Generic																						Generic	5.00	12.50									5.00	5.00	12.50								5.00			
H7220	004	0	1	02	01	H7220_004_0	8	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H7220	004	0	1	02	01	H7220_004_0	8	1	4	3	Generic	010000	1	2	2	Generic	111000000001110000000	31	90									29	31	90								31	1	Generic	2	Generic																						Generic	10.00	20.00									10.00	10.00	20.00								10.00	1	1	
H7220	004	0	1	02	01	H7220_004_0	8	4	4	1	Specialty	100011	1	1	1	Specialty	110000000001100000000	31										29	31									31		Specialty	1	Specialty	30										30	30									30	Specialty																								
H7220	004	0	1	02	01	H7220_004_0	8	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	90									29	31	90								31	1	Non-Preferred Brand	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	8	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	31	90									29	31	90								31	1	Generic	2	Generic																						Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H7220	004	0	1	02	01	H7220_004_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001110000000	31	90									29	31	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	70.00									35.00	35.00	70.00								35.00			
H7220	004	0	1	02	01	H7220_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																						2		
H7220	004	0	1	02	01	H7220_004_0	8	4	4	3	Specialty	100011	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H7226	001	0	1	09	04	H7226_001_0	2	3	4	3	Tier 3	010010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H7226	001	0	1	09	04	H7226_001_0	2	2	4	3	Tier 2	010001	3	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H7226	001	0	1	09	04	H7226_001_0	2	1	4	3	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00	1	1	
H7226	001	0	1	09	04	H7226_001_0	2	3	4	1	Tier 3	010010	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00			
H7226	001	0	1	09	04	H7226_001_0	2	1	4	1	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00			
H7226	001	0	1	09	04	H7226_001_0	2	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H7226	002	0	1	09	04	H7226_002_0	2	1	4	1	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00			
H7226	002	0	1	09	04	H7226_002_0	2	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	2	3	4	1	Tier 3	010010	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			175.00								70.00			
H7226	007	0	1	09	04	H7226_007_0	2	1	4	1	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00			
H7226	007	0	1	09	04	H7226_007_0	2	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	2	3	4	1	Tier 3	010010	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00			
H7226	007	0	1	09	04	H7226_007_0	2	1	4	3	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00	1	1	
H7226	007	0	1	09	04	H7226_007_0	2	2	4	3	Tier 2	010001	3	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H7226	007	0	1	09	04	H7226_007_0	2	3	4	3	Tier 3	010010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H7226	008	0	1	09	04	H7226_008_0	2	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	2	1	4	1	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00			
H7226	008	0	1	09	04	H7226_008_0	2	3	4	1	Tier 3	010010	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			175.00								70.00			
H7226	011	0	1	09	04	H7226_011_0	2	1	4	3	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00	1	1	
H7226	011	0	1	09	04	H7226_011_0	2	2	4	3	Tier 2	010001	3	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H7226	011	0	1	09	04	H7226_011_0	2	3	4	3	Tier 3	010010	3	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H7226	011	0	1	09	04	H7226_011_0	2	3	4	1	Tier 3	010010	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			150.00								60.00			
H7226	011	0	1	09	04	H7226_011_0	2	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 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	2	1	4	1	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00			
H7226	013	0	1	09	04	H7226_013_0	2	3	4	1	Tier 3	010010	3	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			175.00								70.00			
H7226	013	0	1	09	04	H7226_013_0	2	2	4	1	Tier 2	010001	3	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			87.50								35.00			
H7226	013	0	1	09	04	H7226_013_0	2	1	4	1	Tier 1	010001	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00			25.00								10.00			
H7252	002	0	1	01	01	H7252_002_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H7252	002	0	1	01	01	H7252_002_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H7252	002	0	1	01	01	H7252_002_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H7252	002	0	1	01	01	H7252_002_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H7252	002	0	1	01	01	H7252_002_0	4	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H7252	002	0	1	01	01	H7252_002_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H7252	002	0	1	01	01	H7252_002_0	4	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H7252	002	0	1	01	01	H7252_002_0	4	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H7252	003	0	1	01	01	H7252_003_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00			75.00								30.00			
H7252	003	0	1	01	01	H7252_003_0	4	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
H7252	003	0	1	01	01	H7252_003_0	4	3	4	1	Tier 3	100000	1	2	2	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			195.00								70.00			
H7252	003	0	1	01	01	H7252_003_0	4	4	4	1	Tier 4	010010	1	1	1	Tier 4	110000000010100000000	30									30		30									31		Tier 4	1	Tier 4	20									20		20									20	Tier 4																								
H7252	003	0	1	01	01	H7252_003_0	4	1	4	3	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00	1	1	
H7252	003	0	1	01	01	H7252_003_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H7252	003	0	1	01	01	H7252_003_0	4	4	4	3	Tier 4	010010	1	1	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H7252	003	0	1	01	01	H7252_003_0	4	3	4	3	Tier 3	100000	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H7281	001	0	1	02	01	H7281_001_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H7281	001	0	1	02	01	H7281_001_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H7281	001	0	1	02	01	H7281_001_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H7281	001	0	1	02	01	H7281_001_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	26	26								26		26	26								26	Specialty																								
H7281	002	0	1	02	01	H7281_002_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H7281	002	0	1	02	01	H7281_002_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H7281	002	0	1	02	01	H7281_002_0	2	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	140.00								70.00			
H7281	002	0	1	02	01	H7281_002_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H7281	005	0	1	01	01	H7281_005_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00		0.00	0.00								0.00			
H7281	005	0	1	01	01	H7281_005_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		40.00	80.00								40.00			
H7281	005	0	1	01	01	H7281_005_0	3	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H7281	005	0	1	01	01	H7281_005_0	3	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	26	26								26		26	26								26	Specialty																								
H7281	005	0	1	01	01	H7281_005_0	3	5	4	1	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00			
H7281	005	0	1	01	01	H7281_005_0	3	1	4	3	Generic	010000	1	2	2	Generic																								Generic		Generic																						Generic																						2		
H7281	005	0	1	01	01	H7281_005_0	3	2	4	3	Preferred Brand	010011	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H7281	005	0	1	01	01	H7281_005_0	3	5	4	3	Preferred Diabetic Drugs	010010	1	2	2	Preferred Diabetic Drugs	111000000010110000000	31	90								31		31	90								31	2	Preferred Diabetic Drugs	2	Preferred Diabetic Drugs																						Preferred Diabetic Drugs	0.00	0.00								0.00		0.00	0.00								0.00	1	1	
H7281	005	0	1	01	01	H7281_005_0	3	4	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H7281	005	0	1	01	01	H7281_005_0	3	3	4	3	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H7292	001	0	1	01	01	H7292_001_0	7	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010100000000	30	90								30		30									31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00									0.00			
H7292	001	0	1	01	01	H7292_001_0	7	2	4	1	Tier 2	000010	1	2	1	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			135.00								45.00			
H7292	001	0	1	01	01	H7292_001_0	7	3	4	1	Tier 3	010010	1	1	2	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	1	Tier 3	25	25								25			25								25	Tier 3																								
H7301	002	0	1	04	01	H7301_002_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
H7301	002	0	1	04	01	H7301_002_0	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H7301	002	0	1	04	01	H7301_002_0	8	3	4	1	Non-preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-preferred Generic/Non-Preferred Brand	2	Non-preferred Generic/Non-Preferred Brand																						Non-preferred Generic/Non-Preferred Brand	65.00	195.00								65.00			195.00								65.00			
H7301	002	0	1	04	01	H7301_002_0	8	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
H7306	001	0	1	04	01	H7306_001_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H7306	001	0	1	04	01	H7306_001_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H7306	001	0	1	04	01	H7306_001_0	4	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H7306	001	0	1	04	01	H7306_001_0	4	4	4	1	Specialty-Generic and Brand	010010	1	1	2	Specialty-Generic and Brand	110000000010000000000	30									30											31		Specialty-Generic and Brand	1	Specialty-Generic and Brand	33									33											33	Specialty-Generic and Brand																								
H7406	001	0	1	09	04	H7406_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00			
H7406	001	0	1	09	04	H7406_001_0	4	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	4	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	4	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H7406	004	0	1	09	04	H7406_004_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		7.00	14.00								7.00			
H7406	004	0	1	09	04	H7406_004_0	4	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	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	4	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	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	4	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H7526	001	0	1	01	01	H7526_001_0	6	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H7526	001	0	1	01	01	H7526_001_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H7526	001	0	1	01	01	H7526_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	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	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H7526	003	0	1	01	01	H7526_003_0	6	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H7526	003	0	1	01	01	H7526_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	67.00	201.00								67.00			134.00								67.00			
H7526	003	0	1	01	01	H7526_003_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H7526	003	0	1	01	01	H7526_003_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H7526	004	0	1	01	01	H7526_004_0	6	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H7526	004	0	1	01	01	H7526_004_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	102.00								34.00			68.00								34.00			
H7526	004	0	1	01	01	H7526_004_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	67.00	201.00								67.00			134.00								67.00			
H7526	004	0	1	01	01	H7526_004_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H7678	001	0	1	01	01	H7678_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	95.00	285.00								95.00			285.00								95.00			
H7678	001	0	1	01	01	H7678_001_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			135.00								45.00			
H7678	001	0	1	01	01	H7678_001_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H7678	001	0	1	01	01	H7678_001_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H7678	002	0	1	01	01	H7678_002_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H7678	002	0	1	01	01	H7678_002_0	4	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H7678	002	0	1	01	01	H7678_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	150.00								75.00			150.00								75.00			
H7678	002	0	1	01	01	H7678_002_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	75.00								35.00			75.00								35.00			
H7731	001	0	1	01	01	H7731_001_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									10		90								31	2	Tier 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	4	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000001010000000	30	90									10		90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00		0.00								0.00			
H7731	001	0	1	01	01	H7731_001_0	4	3	4	3	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									10		90								31	2	Tier 3	2	Tier 3																						Tier 3	50.00	150.00									50.00		100.00								50.00	1	1	
H7731	001	0	1	01	01	H7731_001_0	4	4	4	3	Tier 4	010011	1	1	2	Tier 4	111000000001010000000	30	90									10		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																						1	1	
H7731	001	0	1	01	01	H7731_001_0	4	2	4	3	Tier 2	000001	1	2	2	Tier 2	111000000001010000000	30	90									10		90								31	2	Tier 2	2	Tier 2																						Tier 2	15.00	45.00									15.00		30.00								15.00	1	1	
H7731	001	0	1	01	01	H7731_001_0	4	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000001010000000	30	90									10		90								31	2	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00		0.00								0.00	1	1	
H7731	001	0	1	01	01	H7731_001_0	4	4	4	1	Tier 4	010011	1	1	2	Tier 4	111000000001010000000	30	90									10		90								31	2	Tier 4	1	Tier 4	25	25									25		25								25	Tier 4																								
H7731	001	0	1	01	01	H7731_001_0	4	3	4	1	Tier 3	000010	1	2	1	Tier 3	111000000001010000000	30	90									10		90								31	2	Tier 3	2	Tier 3																						Tier 3	50.00	150.00									50.00		100.00								50.00			
H7787	001	0	1	04	01	H7787_001_0	8	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H7787	001	0	1	04	01	H7787_001_0	8	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H7787	001	0	1	04	01	H7787_001_0	8	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H7787	001	0	1	04	01	H7787_001_0	8	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7787	001	0	1	04	01	H7787_001_0	8	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H7787	001	0	1	04	01	H7787_001_0	8	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	8	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H7787	001	0	1	04	01	H7787_001_0	8	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H7787	001	0	1	04	01	H7787_001_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7787	001	0	1	04	01	H7787_001_0	8	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00	1	1	
H7787	003	0	1	04	01	H7787_003_0	4	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H7787	003	0	1	04	01	H7787_003_0	4	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	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	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H7787	003	0	1	04	01	H7787_003_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	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	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
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																						2		
H7787	003	0	1	04	01	H7787_003_0	4	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H7787	003	0	1	04	01	H7787_003_0	4	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H7787	003	0	1	04	01	H7787_003_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7787	004	0	1	04	01	H7787_004_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50			
H7787	004	0	1	04	01	H7787_004_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50			
H7787	004	0	1	04	01	H7787_004_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			120.00								40.00			
H7787	004	0	1	04	01	H7787_004_0	4	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	1	Non-Preferred Brand	33	33								33			33								33	Non-Preferred Brand																								
H7787	004	0	1	04	01	H7787_004_0	4	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H7787	004	0	1	04	01	H7787_004_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.50	7.50								2.50			7.50								2.50	1	1	
H7787	004	0	1	04	01	H7787_004_0	4	2	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	7.50	22.50								7.50			22.50								7.50	1	1	
H7787	004	0	1	04	01	H7787_004_0	4	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H7787	004	0	1	04	01	H7787_004_0	4	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H7787	004	0	1	04	01	H7787_004_0	4	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H7787	005	0	1	04	01	H7787_005_0	5	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H7787	005	0	1	04	01	H7787_005_0	5	5	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H7787	005	0	1	04	01	H7787_005_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H7787	005	0	1	04	01	H7787_005_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H7787	005	0	1	04	01	H7787_005_0	5	3	4	3	Preferred Brand	000001	3	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H7787	005	0	1	04	01	H7787_005_0	5	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H7787	005	0	1	04	01	H7787_005_0	5	3	4	1	Preferred Brand	000001	3	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H7787	005	0	1	04	01	H7787_005_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			12.00								4.00			
H7787	005	0	1	04	01	H7787_005_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	0.00	0.00								0.00			0.00								0.00			
H7787	005	0	1	04	01	H7787_005_0	5	5	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H7908	001	0	1	01	01	H7908_001_0	5	1	4	1	Tier 1 - Preferred Generic	001000	1	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	10.00	30.00									10.00					20.00			30.00		10.00			
H7908	001	0	1	01	01	H7908_001_0	5	2	4	1	Tier 2 - Non-Preferred Generic	000100	1	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	33.00	99.00									33.00					66.00			99.00		33.00			
H7908	001	0	1	01	01	H7908_001_0	5	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					68.00			102.00		34.00			
H7908	001	0	1	01	01	H7908_001_0	5	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					156.00			234.00		78.00			
H7908	001	0	1	01	01	H7908_001_0	5	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
H7917	004	0	1	04	01	H7917_004_0	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	004	0	1	04	01	H7917_004_0	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	65.00	195.00								65.00		65.00	162.50								65.00			
H7917	004	0	1	04	01	H7917_004_0	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	45.00	135.00								45.00		45.00	112.50								45.00			
H7917	004	0	1	04	01	H7917_004_0	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	004	0	1	04	01	H7917_004_0	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	005	0	1	04	01	H7917_005_0	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	45.00	135.00								45.00		45.00	112.50								45.00			
H7917	005	0	1	04	01	H7917_005_0	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	65.00	195.00								65.00		65.00	162.50								65.00			
H7917	005	0	1	04	01	H7917_005_0	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	005	0	1	04	01	H7917_005_0	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	005	0	1	04	01	H7917_005_0	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	006	0	1	04	01	H7917_006_0	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	006	0	1	04	01	H7917_006_0	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	006	0	1	04	01	H7917_006_0	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	45.00	135.00								45.00		45.00	112.50								45.00			
H7917	006	0	1	04	01	H7917_006_0	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	006	0	1	04	01	H7917_006_0	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	65.00	195.00								65.00		65.00	162.50								65.00			
H7917	007	0	1	04	01	H7917_007_0	4	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	007	0	1	04	01	H7917_007_0	4	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	007	0	1	04	01	H7917_007_0	4	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	65.00	195.00								65.00		65.00	162.50								65.00			
H7917	007	0	1	04	01	H7917_007_0	4	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	45.00	135.00								45.00		45.00	112.50								45.00			
H7917	007	0	1	04	01	H7917_007_0	4	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	008	0	1	04	01	H7917_008_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	008	0	1	04	01	H7917_008_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	008	0	1	04	01	H7917_008_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	008	0	1	04	01	H7917_008_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	008	0	1	04	01	H7917_008_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	009	0	1	04	01	H7917_009_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	009	0	1	04	01	H7917_009_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	009	0	1	04	01	H7917_009_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	009	0	1	04	01	H7917_009_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	009	0	1	04	01	H7917_009_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	010	0	1	04	01	H7917_010_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	010	0	1	04	01	H7917_010_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	010	0	1	04	01	H7917_010_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	010	0	1	04	01	H7917_010_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	010	0	1	04	01	H7917_010_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	011	0	1	04	01	H7917_011_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	011	0	1	04	01	H7917_011_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	011	0	1	04	01	H7917_011_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	011	0	1	04	01	H7917_011_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	011	0	1	04	01	H7917_011_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	012	0	1	04	01	H7917_012_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	012	0	1	04	01	H7917_012_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	012	0	1	04	01	H7917_012_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	012	0	1	04	01	H7917_012_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	012	0	1	04	01	H7917_012_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	013	0	1	04	01	H7917_013_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	013	0	1	04	01	H7917_013_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	013	0	1	04	01	H7917_013_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	013	0	1	04	01	H7917_013_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	013	0	1	04	01	H7917_013_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	014	0	1	04	01	H7917_014_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	014	0	1	04	01	H7917_014_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	014	0	1	04	01	H7917_014_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	014	0	1	04	01	H7917_014_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	014	0	1	04	01	H7917_014_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H7917	015	0	1	04	01	H7917_015_0	3	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
H7917	015	0	1	04	01	H7917_015_0	3	2	4	1	Tier 2	010000	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	10.00	30.00								10.00		10.00	25.00								10.00			
H7917	015	0	1	04	01	H7917_015_0	3	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	55.00	165.00								55.00		55.00	137.50								55.00			
H7917	015	0	1	04	01	H7917_015_0	3	3	4	1	Tier 3	000001	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	30.00	90.00								30.00		30.00	75.00								30.00			
H7917	015	0	1	04	01	H7917_015_0	3	5	4	1	Tier 5	000010	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
H8050	001	0	1	02	01	H8050_001_0	5	3	4	1	Non-Preferred	110010	1	2	2	Non-Preferred	111000000001010000000	30	90									14		90								34	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	65.00	195.00									65.00		195.00								65.00			
H8050	001	0	1	02	01	H8050_001_0	5	2	4	1	Preferred	010011	1	2	1	Preferred	111000000001010000000	30	90									14		90								34	2	Preferred	2	Preferred																						Preferred	35.00	105.00									35.00		105.00								35.00			
H8050	001	0	1	02	01	H8050_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									14		90								34	2	Generic	2	Generic																						Generic	5.00	15.00									5.00		15.00								5.00			
H8050	001	0	1	02	01	H8050_001_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000001110000000	30	90									14	30	90								34	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H8050	005	0	1	01	01	H8050_005_0	6	4	2	1	Specialty	010010		1	2	Specialty	111000000001110000000	30	90									14	30	90								34	2	Specialty	1	Specialty	25	25									25	25	25								25	Specialty																								
H8050	005	0	1	01	01	H8050_005_0	6	1	2	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									14		90								34	2	Generic	2	Generic																						Generic	4.00	12.00									4.00		12.00								4.00			
H8050	005	0	1	01	01	H8050_005_0	6	2	2	1	Preferred	010011		2	1	Preferred	111000000001010000000	30	90									14		90								34	2	Preferred	2	Preferred																						Preferred	30.00	90.00									30.00		90.00								30.00			
H8050	005	0	1	01	01	H8050_005_0	6	3	2	1	Non-Preferred	110010		2	2	Non-Preferred	111000000001010000000	30	90									14		90								34	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	60.00	180.00									60.00		180.00								60.00			
H8050	006	0	1	02	01	H8050_006_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000001110000000	30	90									14	30	90								34	2	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
H8050	006	0	1	02	01	H8050_006_0	5	3	4	1	Non-Preferred	110010	1	2	2	Non-Preferred	111000000001010000000	30	90									14		90								34	2	Non-Preferred	2	Non-Preferred																						Non-Preferred	65.00	195.00									65.00		195.00								65.00			
H8050	006	0	1	02	01	H8050_006_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									14		90								34	2	Generic	2	Generic																						Generic	5.00	15.00									5.00		15.00								5.00			
H8050	006	0	1	02	01	H8050_006_0	5	2	4	1	Preferred	010011	1	2	1	Preferred	111000000001010000000	30	90									14		90								34	2	Preferred	2	Preferred																						Preferred	35.00	105.00									35.00		105.00								35.00			
H8105	001	0	1	04	01	H8105_001_0	5	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H8105	001	0	1	04	01	H8105_001_0	5	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H8105	001	0	1	04	01	H8105_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H8105	001	0	1	04	01	H8105_001_0	5	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H8130	001	0	1	01	01	H8130_001_0	3	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	31	90								31			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H8130	001	0	1	01	01	H8130_001_0	3	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	86.00	258.00								86.00			258.00								86.00			
H8130	001	0	1	01	01	H8130_001_0	3	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H8130	001	0	1	01	01	H8130_001_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	43.00	129.00								43.00			129.00								43.00			
H8130	002	0	1	01	01	H8130_002_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H8130	002	0	1	01	01	H8130_002_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00	1	1	
H8130	002	0	1	01	01	H8130_002_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8130	002	0	1	01	01	H8130_002_0	5	4	4	3	Specialty Drug	010010	1	1	2	Specialty Drug																								Specialty Drug		Specialty Drug																						Specialty Drug																						2		
H8130	002	0	1	01	01	H8130_002_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H8130	002	0	1	01	01	H8130_002_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	0.00	0.00								0.00			0.00								0.00			
H8130	002	0	1	01	01	H8130_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H8130	002	0	1	01	01	H8130_002_0	5	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H8130	003	0	1	01	01	H8130_003_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H8130	003	0	1	01	01	H8130_003_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H8130	003	0	1	01	01	H8130_003_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8130	003	0	1	01	01	H8130_003_0	3	4	4	3	Specialty Drug	010010	1	1	2	Specialty Drug																								Specialty Drug		Specialty Drug																						Specialty Drug																						2		
H8130	003	0	1	01	01	H8130_003_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H8130	003	0	1	01	01	H8130_003_0	3	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H8130	003	0	1	01	01	H8130_003_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H8130	003	0	1	01	01	H8130_003_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00			30.00								10.00			
H8130	004	0	1	01	01	H8130_004_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8130	004	0	1	01	01	H8130_004_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H8130	004	0	1	01	01	H8130_004_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H8130	004	0	1	01	01	H8130_004_0	3	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H8130	004	0	1	01	01	H8130_004_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H8130	004	0	1	01	01	H8130_004_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	15.00	30.00								15.00			30.00								15.00			
H8130	004	0	1	01	01	H8130_004_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H8130	004	0	1	01	01	H8130_004_0	3	4	4	3	Specialty Drug	010010	1	1	2	Specialty Drug																								Specialty Drug		Specialty Drug																						Specialty Drug																						2		
H8130	005	0	1	01	01	H8130_005_0	4	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H8130	005	0	1	01	01	H8130_005_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H8130	005	0	1	01	01	H8130_005_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	10.00	30.00								10.00			30.00								10.00			
H8130	005	0	1	01	01	H8130_005_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H8189	001	0	1	01	01	H8189_001_0	6	4	4	1	Injectables	000001	1	2	1	Injectables	111000000001010000000	30	90									29		90								31	2	Injectables	2	Injectables																						Injectables	88.00	88.00									88.00		88.00								88.00			
H8189	001	0	1	01	01	H8189_001_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000001010000000	30	90									29		90								31	2	Generic	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	Preferred Brand	000001	1	2	2	Preferred Brand	111000000001010000000	30	90									29		90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	34.00	34.00									34.00		34.00								34.00			
H8189	001	0	1	01	01	H8189_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001010000000	30	90									29		90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	88.00	88.00									88.00		88.00								88.00			
H8393	001	0	1	04	01	H8393_001_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H8393	001	0	1	04	01	H8393_001_0	7	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H8393	001	0	1	04	01	H8393_001_0	7	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H8393	001	0	1	04	01	H8393_001_0	7	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H8558	002	0	1	04	01	H8558_002_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H8558	002	0	1	04	01	H8558_002_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H8558	002	0	1	04	01	H8558_002_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
H8558	004	0	1	04	01	H8558_004_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H8558	004	0	1	04	01	H8558_004_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
H8558	004	0	1	04	01	H8558_004_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H8558	006	0	1	04	01	H8558_006_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H8558	006	0	1	04	01	H8558_006_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	35.00	105.00									35.00		70.00								35.00			
H8558	006	0	1	04	01	H8558_006_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H8578	001	0	1	01	01	H8578_001_0	3	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8578	001	0	1	01	01	H8578_001_0	3	2	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H8578	001	0	1	01	01	H8578_001_0	3	1	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H8578	001	0	1	01	01	H8578_001_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H8578	001	0	1	01	01	H8578_001_0	3	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	3	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
H8578	001	0	1	01	01	H8578_001_0	3	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	001	0	1	01	01	H8578_001_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H8578	002	0	1	01	01	H8578_002_0	3	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H8578	002	0	1	01	01	H8578_002_0	3	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	35.00	105.00								35.00			70.00								35.00			
H8578	002	0	1	01	01	H8578_002_0	3	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	002	0	1	01	01	H8578_002_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H8578	004	0	1	01	01	H8578_004_0	5	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	5	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
H8578	004	0	1	01	01	H8578_004_0	5	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	004	0	1	01	01	H8578_004_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H8578	004	0	1	01	01	H8578_004_0	5	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H8578	004	0	1	01	01	H8578_004_0	5	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8578	004	0	1	01	01	H8578_004_0	5	2	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H8578	004	0	1	01	01	H8578_004_0	5	1	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H8578	005	0	1	01	01	H8578_005_0	5	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	35.00	105.00								35.00			70.00								35.00			
H8578	005	0	1	01	01	H8578_005_0	5	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	005	0	1	01	01	H8578_005_0	5	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H8578	005	0	1	01	01	H8578_005_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H8578	007	0	1	01	01	H8578_007_0	3	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
H8578	007	0	1	01	01	H8578_007_0	3	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	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	3	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H8578	007	0	1	01	01	H8578_007_0	3	1	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H8578	007	0	1	01	01	H8578_007_0	3	2	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H8578	007	0	1	01	01	H8578_007_0	3	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8578	007	0	1	01	01	H8578_007_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H8578	007	0	1	01	01	H8578_007_0	3	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	008	0	1	01	01	H8578_008_0	3	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00			130.00								65.00			
H8578	008	0	1	01	01	H8578_008_0	3	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	35.00	105.00								35.00			70.00								35.00			
H8578	008	0	1	01	01	H8578_008_0	3	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	008	0	1	01	01	H8578_008_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	33									33		33									33	Specialty																								
H8578	010	0	1	02	01	H8578_010_0	3	1	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H8578	010	0	1	02	01	H8578_010_0	3	3	4	3	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8578	010	0	1	02	01	H8578_010_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H8578	010	0	1	02	01	H8578_010_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
H8578	010	0	1	02	01	H8578_010_0	3	3	4	1	Non-Preferred Brand	100000	3	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	45.00	135.00								45.00			90.00								45.00			
H8578	010	0	1	02	01	H8578_010_0	3	2	4	1	Brand	000001	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
H8578	010	0	1	02	01	H8578_010_0	3	1	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8578	010	0	1	02	01	H8578_010_0	3	2	4	3	Brand	000001	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H8604	001	0	1	04	01	H8604_001_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H8604	001	0	1	04	01	H8604_001_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H8604	001	0	1	04	01	H8604_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8604	001	0	1	04	01	H8604_001_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H8604	001	0	1	04	01	H8604_001_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8604	001	0	1	04	01	H8604_001_0	5	4	4	3	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	2	Specialty																						Specialty	10.00									10.00		10.00									10.00	1	2	01000000
H8604	001	0	1	04	01	H8604_001_0	5	4	4	1	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	20									20		20									20	Specialty																								
H8604	001	0	1	04	01	H8604_001_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																								
H8604	003	0	1	04	01	H8604_003_0	5	4	4	1	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	20									20		20									20	Specialty																								
H8604	003	0	1	04	01	H8604_003_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																								
H8604	003	0	1	04	01	H8604_003_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00	1	1	
H8604	003	0	1	04	01	H8604_003_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	10.00	30.00								10.00			20.00								10.00			
H8604	003	0	1	04	01	H8604_003_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
H8604	003	0	1	04	01	H8604_003_0	5	4	4	3	Specialty	010001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	2	Specialty																						Specialty	10.00									10.00		10.00									10.00	1	2	01000000
H8604	003	0	1	04	01	H8604_003_0	5	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8604	003	0	1	04	01	H8604_003_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H8644	003	0	1	04	01	H8644_003_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8644	003	0	1	04	01	H8644_003_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H8644	003	0	1	04	01	H8644_003_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8644	003	0	1	04	01	H8644_003_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8644	003	0	1	04	01	H8644_003_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H8644	003	0	1	04	01	H8644_003_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
H8644	003	0	1	04	01	H8644_003_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8644	003	0	1	04	01	H8644_003_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
H8649	002	0	1	02	01	H8649_002_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
H8649	002	0	1	02	01	H8649_002_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H8649	002	0	1	02	01	H8649_002_0	9	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	70.00	210.00								70.00			210.00								70.00			
H8649	002	0	1	02	01	H8649_002_0	9	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H8649	003	0	1	02	01	H8649_003_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H8649	003	0	1	02	01	H8649_003_0	9	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
H8649	003	0	1	02	01	H8649_003_0	9	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H8649	003	0	1	02	01	H8649_003_0	9	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	74.00	222.00								74.00			222.00								74.00			
H8684	001	0	1	04	01	H8684_001_0	5	3	3	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	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			
H8684	001	0	1	04	01	H8684_001_0	5	5	3	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
H8684	001	0	1	04	01	H8684_001_0	5	1	3	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	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			
H8684	001	0	1	04	01	H8684_001_0	5	2	3	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	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			
H8684	001	0	1	04	01	H8684_001_0	5	4	3	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	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			
H8707	001	0	1	04	01	H8707_001_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H8707	001	0	1	04	01	H8707_001_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8707	001	0	1	04	01	H8707_001_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H8707	001	0	1	04	01	H8707_001_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8707	001	0	1	04	01	H8707_001_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H8707	001	0	1	04	01	H8707_001_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H8707	001	0	1	04	01	H8707_001_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8707	001	0	1	04	01	H8707_001_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8707	003	0	1	04	01	H8707_003_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H8707	003	0	1	04	01	H8707_003_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8707	003	0	1	04	01	H8707_003_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8707	003	0	1	04	01	H8707_003_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8707	003	0	1	04	01	H8707_003_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H8707	003	0	1	04	01	H8707_003_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H8707	003	0	1	04	01	H8707_003_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H8707	003	0	1	04	01	H8707_003_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8707	005	0	1	04	01	H8707_005_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8707	005	0	1	04	01	H8707_005_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8707	005	0	1	04	01	H8707_005_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H8707	005	0	1	04	01	H8707_005_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H8707	005	0	1	04	01	H8707_005_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H8707	005	0	1	04	01	H8707_005_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8707	005	0	1	04	01	H8707_005_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H8707	005	0	1	04	01	H8707_005_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8707	006	0	1	04	01	H8707_006_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H8707	006	0	1	04	01	H8707_006_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8707	006	0	1	04	01	H8707_006_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8707	006	0	1	04	01	H8707_006_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00			
H8707	006	0	1	04	01	H8707_006_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8707	006	0	1	04	01	H8707_006_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8707	006	0	1	04	01	H8707_006_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H8707	006	0	1	04	01	H8707_006_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00					0.00	0.00		6.00	18.00		6.00	1	2	00001000
H8707	007	0	1	04	01	H8707_007_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8707	007	0	1	04	01	H8707_007_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8707	007	0	1	04	01	H8707_007_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H8707	007	0	1	04	01	H8707_007_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H8707	007	0	1	04	01	H8707_007_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8707	007	0	1	04	01	H8707_007_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8707	007	0	1	04	01	H8707_007_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H8707	007	0	1	04	01	H8707_007_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H8742	001	0	1	01	01	H8742_001_0	10	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H8742	001	0	1	01	01	H8742_001_0	10	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H8742	001	0	1	01	01	H8742_001_0	10	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H8742	001	0	1	01	01	H8742_001_0	10	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H8742	008	0	1	01	01	H8742_008_0	9	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00			
H8742	008	0	1	01	01	H8742_008_0	9	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00			
H8742	008	0	1	01	01	H8742_008_0	9	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	162.50								65.00											65.00			
H8742	008	0	1	01	01	H8742_008_0	9	4	4	1	Specialty	000001	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	33									33											33	Specialty																								
H8742	008	0	1	01	01	H8742_008_0	9	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00											5.00	1	1	
H8742	008	0	1	01	01	H8742_008_0	9	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	87.50								35.00											35.00	1	2	10000000
H8742	008	0	1	01	01	H8742_008_0	9	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H8742	008	0	1	01	01	H8742_008_0	9	4	4	3	Specialty	000001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H8748	001	0	1	02	01	H8748_001_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H8748	001	0	1	02	01	H8748_001_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	4.00	12.00								4.00						8.00			12.00		4.00			
H8748	001	0	1	02	01	H8748_001_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H8748	001	0	1	02	01	H8748_001_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H8748	002	0	1	02	01	H8748_002_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00			
H8748	002	0	1	02	01	H8748_002_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H8748	002	0	1	02	01	H8748_002_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H8748	002	0	1	02	01	H8748_002_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H8748	003	0	1	02	01	H8748_003_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	4.00	12.00								4.00						8.00			12.00		4.00			
H8748	003	0	1	02	01	H8748_003_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H8748	003	0	1	02	01	H8748_003_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H8748	003	0	1	02	01	H8748_003_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H8748	004	0	1	02	01	H8748_004_0	3	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H8748	004	0	1	02	01	H8748_004_0	3	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H8748	004	0	1	02	01	H8748_004_0	3	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00			
H8748	004	0	1	02	01	H8748_004_0	3	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
H8778	001	0	1	01	01	H8778_001_0	6	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H8778	001	0	1	01	01	H8778_001_0	6	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	59.00	118.00									59.00	59.00	118.00								59.00			
H8778	001	0	1	01	01	H8778_001_0	6	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H8778	001	0	1	01	01	H8778_001_0	6	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H8778	004	0	1	01	01	H8778_004_0	7	1	4	1	Tier 1 Generic	010000	1	2	2	Tier 1 Generic	111000000001110000000	31	93									14	31	93								34	1	Tier 1 Generic	2	Tier 1 Generic																						Tier 1 Generic	5.00	10.00									5.00	5.00	10.00								5.00			
H8778	004	0	1	01	01	H8778_004_0	7	2	4	1	Tier 2 Preferred Brand	000001	1	2	1	Tier 2 Preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	29.00	58.00									29.00	29.00	58.00								29.00			
H8778	004	0	1	01	01	H8778_004_0	7	3	4	1	Tier 3 Non-preferred Brand	100000	1	2	2	Tier 3 Non-preferred Brand	111000000001110000000	31	93									14	31	93								34	1	Tier 3 Non-preferred Brand	2	Tier 3 Non-preferred Brand																						Tier 3 Non-preferred Brand	59.00	118.00									59.00	59.00	118.00								59.00			
H8778	004	0	1	01	01	H8778_004_0	7	4	4	1	Tier 4 Specialty	100011	1	1	2	Tier 4 Specialty	111000000001110000000	31	93									14	31	93								34	1	Tier 4 Specialty	1	Tier 4 Specialty	20	20									20	20	20								20	Tier 4 Specialty																								
H8822	002	0	1	01	01	H8822_002_0	4	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H8822	002	0	1	01	01	H8822_002_0	4	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H8822	002	0	1	01	01	H8822_002_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H8822	002	0	1	01	01	H8822_002_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H8822	002	0	1	01	01	H8822_002_0	4	5	4	3	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents																								Non-Preferred Agents		Non-Preferred Agents																						Non-Preferred Agents																						2		
H8822	002	0	1	01	01	H8822_002_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H8822	002	0	1	01	01	H8822_002_0	4	2	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H8822	002	0	1	01	01	H8822_002_0	4	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H8822	002	0	1	01	01	H8822_002_0	4	5	4	1	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Agents	2	Non-Preferred Agents																						Non-Preferred Agents	80.00	240.00								80.00		80.00	160.00								80.00			
H8822	002	0	1	01	01	H8822_002_0	4	4	4	1	Specialty	000010	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H8822	003	0	1	01	01	H8822_003_0	4	5	4	1	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Agents	2	Non-Preferred Agents																						Non-Preferred Agents	80.00	240.00								80.00		80.00	160.00								80.00			
H8822	003	0	1	01	01	H8822_003_0	4	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H8822	003	0	1	01	01	H8822_003_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H8822	003	0	1	01	01	H8822_003_0	4	4	4	1	Specialty	000010	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H8822	003	0	1	01	01	H8822_003_0	4	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H8822	004	0	1	01	01	H8822_004_0	3	2	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H8822	004	0	1	01	01	H8822_004_0	3	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00	1	1	
H8822	004	0	1	01	01	H8822_004_0	3	5	4	1	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents	111000000010110000000	30	90								30		30	90								31	2	Non-Preferred Agents	2	Non-Preferred Agents																						Non-Preferred Agents	80.00	240.00								80.00		80.00	160.00								80.00			
H8822	004	0	1	01	01	H8822_004_0	3	4	4	1	Specialty	000010	1	1	1	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H8822	004	0	1	01	01	H8822_004_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H8822	004	0	1	01	01	H8822_004_0	3	2	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H8822	004	0	1	01	01	H8822_004_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010110000000	30	90								30		30	90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00		8.00	16.00								8.00			
H8822	004	0	1	01	01	H8822_004_0	3	5	4	3	Non-Preferred Agents	100000	1	2	2	Non-Preferred Agents																								Non-Preferred Agents		Non-Preferred Agents																						Non-Preferred Agents																						2		
H8822	004	0	1	01	01	H8822_004_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H8822	004	0	1	01	01	H8822_004_0	3	4	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H8953	001	0	1	01	01	H8953_001_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H8953	001	0	1	01	01	H8953_001_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
H8953	001	0	1	01	01	H8953_001_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H8953	001	0	1	01	01	H8953_001_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00			
H8953	001	0	1	01	01	H8953_001_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00			
H8953	001	0	1	01	01	H8953_001_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00					0.00	0.00		5.00	15.00		5.00	1	1	
H8953	001	0	1	01	01	H8953_001_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H8953	001	0	1	01	01	H8953_001_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H8980	002	0	1	04	01	H8980_002_0	10	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			10.00								4.00			
H8980	002	0	1	04	01	H8980_002_0	10	3	4	1	Tier 3 Non-Preferred Generic / Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic / Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 Non-Preferred Generic / Non-Preferred Brand	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			
H8980	002	0	1	04	01	H8980_002_0	10	4	4	1	Tier 4 Specialty Drugs	010010	1	1	2	Tier 4 Specialty Drugs	110000000010000000000	30									30											31		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	33									33											33	Tier 4 Specialty Drugs																								
H8980	002	0	1	04	01	H8980_002_0	10	2	4	1	Tier 2 Preferred Brand	000001	1	2	2	Tier 2 Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00								41.00			102.50								41.00			
H8980	003	0	1	04	01	H8980_003_0	8	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H8980	003	0	1	04	01	H8980_003_0	8	2	4	1	Tier 2 Preferred Generic	000001	1	2	2	Tier 2 Preferred Generic	111000000010010000000	30	90								30			90								31	2	Tier 2 Preferred Generic	2	Tier 2 Preferred Generic																						Tier 2 Preferred Generic	35.00	105.00								35.00			87.50								35.00			
H8980	003	0	1	04	01	H8980_003_0	8	3	4	1	Tier 3 Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Tier 3 Non-Preferred Generic/Non-Preferred Brand	2	Tier 3 Non-Preferred Generic/Non-Preferred Brand																						Tier 3 Non-Preferred Generic/Non-Preferred Brand	73.00	219.00								73.00			219.00								73.00			
H8980	003	0	1	04	01	H8980_003_0	8	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	110000000010000000000	30									30											31		Tier 4 Specialty	1	Tier 4 Specialty	33									33											33	Tier 4 Specialty																								
H8991	012	0	1	01	01	H8991_012_0	3	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H8991	012	0	1	01	01	H8991_012_0	3	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H8991	012	0	1	01	01	H8991_012_0	3	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H8991	012	0	1	01	01	H8991_012_0	3	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H8991	012	0	1	01	01	H8991_012_0	3	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H8991	012	0	1	01	01	H8991_012_0	3	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	20.00	60.00	40.00							20.00		20.00	40.00	30.00							20.00			
H8991	012	0	1	01	01	H8991_012_0	3	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	5.00	15.00	10.00							5.00		5.00	10.00	7.50							5.00			
H8991	012	0	1	01	01	H8991_012_0	3	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H8991	012	0	1	01	01	H8991_012_0	3	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	3	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	3	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H8991	017	0	1	01	01	H8991_017_0	3	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H8991	017	0	1	01	01	H8991_017_0	3	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H8991	017	0	1	01	01	H8991_017_0	3	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H8991	017	0	1	01	01	H8991_017_0	3	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H8991	017	0	1	01	01	H8991_017_0	3	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	25	25	25							25		25	25	25							25	Specialty Drugs																								
H8991	017	0	1	01	01	H8991_017_0	3	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	90.00	270.00	180.00							90.00		90.00	180.00	135.00							90.00			
H8991	017	0	1	01	01	H8991_017_0	3	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	3	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	47.00	141.00	94.00							47.00		47.00	94.00	70.50							47.00			
H8991	017	0	1	01	01	H8991_017_0	3	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	4	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H8991	018	0	1	01	01	H8991_018_0	4	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H8991	018	0	1	01	01	H8991_018_0	4	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	4	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs	5.00	15.00	10.00							5.00		5.00	10.00	7.50							5.00			
H8991	018	0	1	01	01	H8991_018_0	4	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H8991	018	0	1	01	01	H8991_018_0	4	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	80.00	240.00	160.00							80.00		80.00	160.00	120.00							80.00			
H8991	018	0	1	01	01	H8991_018_0	4	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H8991	018	0	1	01	01	H8991_018_0	4	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H8991	018	0	1	01	01	H8991_018_0	4	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H8991	018	0	1	01	01	H8991_018_0	4	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	25.00	75.00	50.00							25.00		25.00	50.00	37.50							25.00			
H8991	022	0	1	01	01	H8991_022_0	3	2	4	1	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Generic Drugs	2	Non-Preferred Generic Drugs																						Non-Preferred 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	3	3	4	1	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	10.00	30.00	20.00							10.00		10.00	20.00	15.00							10.00			
H8991	022	0	1	01	01	H8991_022_0	3	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
H8991	022	0	1	01	01	H8991_022_0	3	4	4	3	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
H8991	022	0	1	01	01	H8991_022_0	3	3	4	3	Preferred Brand Drugs	000001	1	2	2	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
H8991	022	0	1	01	01	H8991_022_0	3	2	4	3	Non-Preferred Generic Drugs	000100	1	2	2	Non-Preferred Generic Drugs																								Non-Preferred Generic Drugs		Non-Preferred Generic Drugs																						Non-Preferred Generic Drugs																						2		
H8991	022	0	1	01	01	H8991_022_0	3	1	4	3	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	0.00	0.00	0.00							0.00		0.00	0.00	0.00							0.00	1	1	
H8991	022	0	1	01	01	H8991_022_0	3	1	4	1	Preferred Generic Drugs	001000	1	2	2	Preferred Generic Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred 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	3	4	4	1	Non-Preferred Brand Drugs	100000	1	2	1	Non-Preferred Brand Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Non-Preferred Brand Drugs	2	Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs	40.00	120.00	80.00							40.00		40.00	80.00	60.00							40.00			
H8991	022	0	1	01	01	H8991_022_0	3	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	111100000010111000000	31	93	62							31		31	93	62							31	2	Specialty Drugs	1	Specialty Drugs	33	33	33							33		33	33	33							33	Specialty Drugs																								
H9001	011	0	1	01	01	H9001_011_0	3	4	4	1	Tier 4	010010	3	1	2	Tier 4	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 4	1	Tier 4	25	25	25							25		25	25	25							25	Tier 4																								
H9001	011	0	1	01	01	H9001_011_0	3	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00			
H9001	011	0	1	01	01	H9001_011_0	3	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 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	3	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	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	4	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H9001	013	0	1	01	01	H9001_013_0	4	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H9001	013	0	1	01	01	H9001_013_0	4	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H9001	014	0	1	01	01	H9001_014_0	3	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00			
H9001	014	0	1	01	01	H9001_014_0	3	4	4	1	Tier 4	010010	3	1	2	Tier 4	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 4	1	Tier 4	25	25	25							25		25	25	25							25	Tier 4																								
H9001	014	0	1	01	01	H9001_014_0	3	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 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	3	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00			
H9001	015	0	1	01	01	H9001_015_0	4	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H9001	015	0	1	01	01	H9001_015_0	4	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H9001	015	0	1	01	01	H9001_015_0	4	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H9001	017	0	1	01	01	H9001_017_0	6	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H9001	017	0	1	01	01	H9001_017_0	6	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H9001	017	0	1	01	01	H9001_017_0	6	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H9001	020	0	1	01	01	H9001_020_0	4	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00			
H9001	020	0	1	01	01	H9001_020_0	4	4	4	1	Tier 4	010010	3	1	2	Tier 4	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 4	1	Tier 4	25	25	25							25		25	25	25							25	Tier 4																								
H9001	020	0	1	01	01	H9001_020_0	4	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00			
H9001	020	0	1	01	01	H9001_020_0	4	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00			
H9001	021	0	1	01	01	H9001_021_0	3	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H9001	021	0	1	01	01	H9001_021_0	3	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H9001	021	0	1	01	01	H9001_021_0	3	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H9001	023	0	1	01	01	H9001_023_0	2	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	20.00	60.00	40.00							20.00		20.00	60.00	40.00							20.00			
H9001	023	0	1	01	01	H9001_023_0	2	4	4	1	Tier 4	010010	3	1	2	Tier 4	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 4	1	Tier 4	25	25	25							25		25	25	25							25	Tier 4																								
H9001	023	0	1	01	01	H9001_023_0	2	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00	80.00							40.00		40.00	120.00	80.00							40.00			
H9001	023	0	1	01	01	H9001_023_0	2	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00	10.00							5.00		5.00	15.00	10.00							5.00			
H9001	024	0	1	01	01	H9001_024_0	3	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H9001	024	0	1	01	01	H9001_024_0	3	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H9001	024	0	1	01	01	H9001_024_0	3	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H9001	025	0	1	01	01	H9001_025_0	3	1	4	1	Tier 1	001000	3	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 1	2	Tier 1																						Tier 1	7.00	21.00	14.00							7.00		7.00	21.00	14.00							7.00			
H9001	025	0	1	01	01	H9001_025_0	3	2	4	1	Tier 2	000101	3	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00	70.00							35.00		35.00	105.00	70.00							35.00			
H9001	025	0	1	01	01	H9001_025_0	3	3	4	1	Tier 3	100000	3	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		65.00	195.00	130.00							65.00			
H9003	001	0	1	01	01	H9003_001_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H9003	001	0	1	01	01	H9003_001_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H9003	001	0	1	01	01	H9003_001_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H9003	001	0	1	01	01	H9003_001_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H9003	001	0	1	01	01	H9003_001_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H9003	001	0	1	01	01	H9003_001_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H9003	006	0	1	01	01	H9003_006_0	5	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H9003	006	0	1	01	01	H9003_006_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00			
H9003	006	0	1	01	01	H9003_006_0	5	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	2	Brand	2	Brand																						Brand	45.00	135.00								45.00		45.00	90.00								45.00			
H9003	006	0	1	01	01	H9003_006_0	5	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H9003	006	0	1	01	01	H9003_006_0	5	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H9003	006	0	1	01	01	H9003_006_0	5	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H9011	003	0	1	01	01	H9011_003_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	10.00	30.00								10.00						20.00			30.00		10.00			
H9011	003	0	1	01	01	H9011_003_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	35.00	105.00								35.00						95.00			105.00		35.00			
H9011	003	0	1	01	01	H9011_003_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H9011	003	0	1	01	01	H9011_003_0	4	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	0.00	0.00								0.00						0.00			0.00		0.00	1	1	
H9011	003	0	1	01	01	H9011_003_0	4	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
H9011	003	0	1	01	01	H9011_003_0	4	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
H9011	003	0	1	01	01	H9011_003_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	0.00	0.00								0.00						0.00			0.00		0.00			
H9011	003	0	1	01	01	H9011_003_0	4	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
H9011	016	0	1	02	01	H9011_016_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	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	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H9011	016	0	1	02	01	H9011_016_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	15.00	45.00								15.00						35.00			45.00		15.00			
H9011	016	0	1	02	01	H9011_016_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	4.00	12.00								4.00						8.00			12.00		4.00			
H9047	001	0	1	01	01	H9047_001_0	9	3	4	1	Specialty	010010	1	1	1	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
H9047	001	0	1	01	01	H9047_001_0	9	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Generic	2	Generic																						Generic				6.00	18.00		9.00	27.00		9.00					6.00	18.00		9.00	27.00		9.00			
H9047	001	0	1	01	01	H9047_001_0	9	2	4	1	Brand	000010	1	2	2	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Brand	2	Brand																						Brand				45.00	135.00		45.00	135.00		45.00					45.00	135.00		45.00	135.00		45.00			
H9047	013	0	2	01	01	H9047_013_0	7	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Generic	2	Generic																						Generic				6.00	18.00		9.00	27.00		9.00					6.00	18.00		9.00	27.00		9.00			
H9047	013	0	2	01	01	H9047_013_0	7	3	4	1	Specialty	010010	1	1	1	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
H9047	013	0	2	01	01	H9047_013_0	7	2	4	1	Brand	000010	1	2	2	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Brand	2	Brand																						Brand				45.00	135.00		45.00	135.00		45.00					45.00	135.00		45.00	135.00		45.00			
H9047	024	0	1	02	01	H9047_024_0	10	2	4	1	Brand	000010	1	2	2	Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Brand	2	Brand																						Brand				45.00	135.00		45.00	135.00		45.00					45.00	135.00		45.00	135.00		45.00			
H9047	024	0	1	02	01	H9047_024_0	10	1	4	1	Generic	010000	1	2	2	Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Generic	2	Generic																						Generic				6.00	18.00		9.00	27.00		9.00					6.00	18.00		9.00	27.00		9.00			
H9047	024	0	1	02	01	H9047_024_0	10	3	4	1	Specialty	010010	1	1	1	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
H9082	002	0	1	01	01	H9082_002_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00			15.00								5.00			
H9082	002	0	1	01	01	H9082_002_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	60.00	180.00								60.00			180.00								60.00			
H9082	002	0	1	01	01	H9082_002_0	6	4	4	1	Specialty Drug	010010	1	1	2	Specialty Drug	111000000010010000000	31	90								31			90								31	1	Specialty Drug	1	Specialty Drug	33	33								33			33								33	Specialty Drug																								
H9082	002	0	1	01	01	H9082_002_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00			90.00								30.00			
H9101	007	0	1	01	01	H9101_007_0	3	2	4	1	Preferred	000001	1	2	1	Preferred	111000000010010000000	30	90								30			90								31	1	Preferred	2	Preferred																						Preferred	25.00	75.00								25.00			62.50								25.00			
H9101	007	0	1	01	01	H9101_007_0	3	3	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	30	90								30			90								31	1	Brand	2	Brand																						Brand	75.00	225.00								75.00			187.50								75.00			
H9101	007	0	1	01	01	H9101_007_0	3	4	4	1	Specialty	100100	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
H9101	007	0	1	01	01	H9101_007_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H9101	007	0	1	01	01	H9101_007_0	3	2	4	3	Preferred	000001	1	2	1	Preferred																								Preferred		Preferred																						Preferred																						2		
H9101	007	0	1	01	01	H9101_007_0	3	4	4	3	Specialty	100100	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H9101	007	0	1	01	01	H9101_007_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H9101	007	0	1	01	01	H9101_007_0	3	3	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H9103	001	0	1	01	01	H9103_001_0	4	2	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
H9103	001	0	1	01	01	H9103_001_0	4	3	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
H9103	001	0	1	01	01	H9103_001_0	4	3	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	2	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
H9103	001	0	1	01	01	H9103_001_0	4	2	4	1	Brand	000010	1	2	1	Brand	111000000010110000000	30	90								30		30	90								31	2	Brand	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	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	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	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00		10.00	20.00								10.00	1	1	
H9104	006	0	1	01	01	H9104_006_0	6	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H9104	006	0	1	01	01	H9104_006_0	6	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H9104	006	0	1	01	01	H9104_006_0	6	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H9104	006	0	1	01	01	H9104_006_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H9104	006	0	1	01	01	H9104_006_0	6	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H9104	006	0	1	01	01	H9104_006_0	6	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	006	0	1	01	01	H9104_006_0	6	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H9104	006	0	1	01	01	H9104_006_0	6	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H9104	006	0	1	01	01	H9104_006_0	6	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H9104	006	0	1	01	01	H9104_006_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H9104	007	0	1	01	01	H9104_007_0	5	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H9104	007	0	1	01	01	H9104_007_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H9104	007	0	1	01	01	H9104_007_0	5	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H9104	007	0	1	01	01	H9104_007_0	5	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	007	0	1	01	01	H9104_007_0	5	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H9104	007	0	1	01	01	H9104_007_0	5	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H9104	007	0	1	01	01	H9104_007_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			12.50								5.00			
H9104	007	0	1	01	01	H9104_007_0	5	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H9104	007	0	1	01	01	H9104_007_0	5	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H9104	007	0	1	01	01	H9104_007_0	5	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H9104	008	0	1	01	01	H9104_008_0	6	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H9104	008	0	1	01	01	H9104_008_0	6	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H9104	008	0	1	01	01	H9104_008_0	6	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H9104	008	0	1	01	01	H9104_008_0	6	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H9104	008	0	1	01	01	H9104_008_0	6	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	008	0	1	01	01	H9104_008_0	6	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H9104	008	0	1	01	01	H9104_008_0	6	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H9104	008	0	1	01	01	H9104_008_0	6	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H9104	008	0	1	01	01	H9104_008_0	6	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H9104	008	0	1	01	01	H9104_008_0	6	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H9104	009	0	1	01	01	H9104_009_0	5	1	4	3	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H9104	009	0	1	01	01	H9104_009_0	5	2	4	3	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00	1	1	
H9104	009	0	1	01	01	H9104_009_0	5	3	4	3	Brand	000010	3	2	2	Brand																								Brand		Brand																						Brand																						2		
H9104	009	0	1	01	01	H9104_009_0	5	5	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H9104	009	0	1	01	01	H9104_009_0	5	4	4	3	Additional Brand	000010	1	2	2	Additional Brand																								Additional Brand		Additional Brand																						Additional Brand																						2		
H9104	009	0	1	01	01	H9104_009_0	5	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	009	0	1	01	01	H9104_009_0	5	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	60.00	180.00								60.00			150.00								60.00			
H9104	009	0	1	01	01	H9104_009_0	5	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H9104	009	0	1	01	01	H9104_009_0	5	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	10.00	30.00								10.00			25.00								10.00			
H9104	009	0	1	01	01	H9104_009_0	5	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H9104	013	0	1	01	01	H9104_013_0	10	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H9104	013	0	1	01	01	H9104_013_0	10	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	34.00	102.00								34.00			85.00								34.00			
H9104	013	0	1	01	01	H9104_013_0	10	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	83.00	249.00								83.00			207.50								83.00			
H9104	013	0	1	01	01	H9104_013_0	10	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	013	0	1	01	01	H9104_013_0	10	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	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	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H9104	014	0	1	01	01	H9104_014_0	10	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	32.00	96.00								32.00			80.00								32.00			
H9104	014	0	1	01	01	H9104_014_0	10	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	89.00	267.00								89.00			222.50								89.00			
H9104	014	0	1	01	01	H9104_014_0	10	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	014	0	1	01	01	H9104_014_0	10	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H9104	015	0	1	01	01	H9104_015_0	9	3	4	1	Brand	000010	3	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	35.00	105.00								35.00			87.50								35.00			
H9104	015	0	1	01	01	H9104_015_0	9	4	4	1	Additional Brand	000010	1	2	2	Additional Brand	111000000010010000000	31	90								31			90								31	2	Additional Brand	2	Additional Brand																						Additional Brand	93.00	279.00								93.00			232.50								93.00			
H9104	015	0	1	01	01	H9104_015_0	9	5	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9104	015	0	1	01	01	H9104_015_0	9	1	4	1	Select Generic	010000	1	2	2	Select Generic	111000000010010000000	31	90								31			90								31	2	Select Generic	2	Select Generic																						Select Generic	0.00	0.00								0.00			0.00								0.00			
H9104	015	0	1	01	01	H9104_015_0	9	2	4	1	Generic	010000	3	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H9149	002	0	1	02	01	H9149_002_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	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	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
H9149	002	0	1	02	01	H9149_002_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
H9149	002	0	1	02	01	H9149_002_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
H9184	001	0	1	04	01	H9184_001_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H9184	001	0	1	04	01	H9184_001_0	4	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H9184	001	0	1	04	01	H9184_001_0	4	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H9184	001	0	1	04	01	H9184_001_0	4	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H9184	002	0	1	04	01	H9184_002_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	31	90								31		31	90								31	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	8.00								4.00			
H9184	002	0	1	04	01	H9184_002_0	4	3	4	1	Non-Preferred Brand	110010	1	2	2	Non-Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00		80.00	160.00								80.00			
H9184	002	0	1	04	01	H9184_002_0	4	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010110000000	31	90								31		31	90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		35.00	70.00								35.00			
H9184	002	0	1	04	01	H9184_002_0	4	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010110000000	31	90								31		31	90								31	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H9302	001	0	1	01	01	H9302_001_0	4	1	4	1	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00			
H9302	001	0	1	01	01	H9302_001_0	4	4	4	1	Tier IV	100100	3	2	1	Tier IV	111000000001110000000	30	90									10	30	90								31	1	Tier IV	2	Tier IV																						Tier IV	59.00	177.00									59.00	59.00	118.00								59.00			
H9302	001	0	1	01	01	H9302_001_0	4	3	4	1	Tier III	010010	3	1	2	Tier III	111000000001110000000	30	90									10	30	90								31	1	Tier III	1	Tier III	20	20									20	20	20								20	Tier III																								
H9302	001	0	1	01	01	H9302_001_0	4	2	4	1	Tier II	010001	3	2	2	Tier II	111000000001110000000	30	90									10	30	90								31	1	Tier II	2	Tier II																						Tier II	29.00	87.00									29.00	29.00	58.00								29.00			
H9302	001	0	1	01	01	H9302_001_0	4	1	4	3	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00	1	1	
H9302	001	0	1	01	01	H9302_001_0	4	2	4	3	Tier II	010001	3	2	2	Tier II																								Tier II		Tier II																						Tier II																						2		
H9302	001	0	1	01	01	H9302_001_0	4	3	4	3	Tier III	010010	3	1	2	Tier III																								Tier III		Tier III																						Tier III																						2		
H9302	001	0	1	01	01	H9302_001_0	4	4	4	3	Tier IV	100100	3	2	1	Tier IV																								Tier IV		Tier IV																						Tier IV																						2		
H9302	003	0	1	01	01	H9302_003_0	4	2	4	1	Tier II	010001	3	2	2	Tier II	111000000001110000000	30	90									10	30	90								31	1	Tier II	2	Tier II																						Tier II	29.00	87.00									29.00	29.00	58.00								29.00			
H9302	003	0	1	01	01	H9302_003_0	4	1	4	1	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00			
H9302	003	0	1	01	01	H9302_003_0	4	3	4	1	Tier III	010010	3	1	2	Tier III	111000000001110000000	30	90									10	30	90								31	1	Tier III	1	Tier III	20	20									20	20	20								20	Tier III																								
H9302	003	0	1	01	01	H9302_003_0	4	4	4	1	Tier IV	100100	3	2	1	Tier IV	111000000001110000000	30	90									10	30	90								31	1	Tier IV	2	Tier IV																						Tier IV	59.00	177.00									59.00	59.00	118.00								59.00			
H9302	005	0	1	01	01	H9302_005_0	4	2	4	3	Tier II	010001	3	2	2	Tier II																								Tier II		Tier II																						Tier II																						2		
H9302	005	0	1	01	01	H9302_005_0	4	4	4	3	Tier IV	100100	3	2	1	Tier IV																								Tier IV		Tier IV																						Tier IV																						2		
H9302	005	0	1	01	01	H9302_005_0	4	3	4	3	Tier III	010010	3	1	2	Tier III																								Tier III		Tier III																						Tier III																						2		
H9302	005	0	1	01	01	H9302_005_0	4	4	4	1	Tier IV	100100	3	2	1	Tier IV	111000000001110000000	30	90									10	30	90								31	1	Tier IV	2	Tier IV																						Tier IV	59.00	177.00									59.00	59.00	118.00								59.00			
H9302	005	0	1	01	01	H9302_005_0	4	1	4	3	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00	1	1	
H9302	005	0	1	01	01	H9302_005_0	4	1	4	1	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00			
H9302	005	0	1	01	01	H9302_005_0	4	2	4	1	Tier II	010001	3	2	2	Tier II	111000000001110000000	30	90									10	30	90								31	1	Tier II	2	Tier II																						Tier II	29.00	87.00									29.00	29.00	58.00								29.00			
H9302	005	0	1	01	01	H9302_005_0	4	3	4	1	Tier III	010010	3	1	2	Tier III	111000000001110000000	30	90									10	30	90								31	1	Tier III	1	Tier III	20	20									20	20	20								20	Tier III																								
H9302	007	0	1	01	01	H9302_007_0	6	4	4	1	Tier IV	100100	1	2	1	Tier IV	111000000001110000000	30	90									10	30	90								31	1	Tier IV	2	Tier IV																						Tier IV	59.00	177.00									59.00	59.00	118.00								59.00			
H9302	007	0	1	01	01	H9302_007_0	6	3	4	1	Tier III	010010	1	1	2	Tier III	111000000001110000000	30	90									10	30	90								31	1	Tier III	1	Tier III	20	20									20	20	20								20	Tier III																								
H9302	007	0	1	01	01	H9302_007_0	6	1	4	1	Tier I	001001	1	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00			
H9302	007	0	1	01	01	H9302_007_0	6	2	4	1	Tier II	010001	1	2	2	Tier II	111000000001110000000	30	90									10	30	90								31	1	Tier II	2	Tier II																						Tier II	29.00	87.00									29.00	29.00	58.00								29.00			
H9302	008	0	1	02	01	H9302_008_0	4	1	4	1	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00			
H9302	008	0	1	02	01	H9302_008_0	4	2	4	1	Tier II	010001	3	2	2	Tier II	111000000001110000000	30	90									10	30	90								31	1	Tier II	2	Tier II																						Tier II	29.00	87.00									29.00	29.00	58.00								29.00			
H9302	008	0	1	02	01	H9302_008_0	4	3	4	1	Tier III	010010	3	1	2	Tier III	111000000001110000000	30	90									10	30	90								31	1	Tier III	1	Tier III	20	20									20	20	20								20	Tier III																								
H9302	008	0	1	02	01	H9302_008_0	4	4	4	1	Tier IV	100100	3	2	1	Tier IV	111000000001110000000	30	90									10	30	90								31	1	Tier IV	2	Tier IV																						Tier IV	59.00	177.00									59.00	59.00	118.00								59.00			
H9302	008	0	1	02	01	H9302_008_0	4	1	4	3	Tier I	001001	3	2	2	Tier I	111000000001110000000	30	90									10	30	90								31	1	Tier I	2	Tier I																						Tier I	5.00	15.00									5.00	5.00	10.00								5.00	1	1	
H9302	008	0	1	02	01	H9302_008_0	4	2	4	3	Tier II	010001	3	2	2	Tier II																								Tier II		Tier II																						Tier II																						2		
H9302	008	0	1	02	01	H9302_008_0	4	3	4	3	Tier III	010010	3	1	2	Tier III																								Tier III		Tier III																						Tier III																						2		
H9302	008	0	1	02	01	H9302_008_0	4	4	4	3	Tier IV	100100	3	2	1	Tier IV																								Tier IV		Tier IV																						Tier IV																						2		
H9313	007	0	1	02	01	H9313_007_0	8	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	50.00	150.00	100.00							50.00		50.00	150.00	100.00							50.00			
H9313	007	0	1	02	01	H9313_007_0	8	2	4	1	Non-Preferred Generic	001000	1	2	2	Non-Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00	30.00							15.00		10.00	30.00	20.00							15.00			
H9313	007	0	1	02	01	H9313_007_0	8	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		3.00	8.00	5.00							4.00			
H9313	007	0	1	02	01	H9313_007_0	8	5	4	1	Specialty	101101	1	1	2	Specialty	111100000010111000000	30	90	60							30		30	90	60							34	1	Specialty	1	Specialty	33	33	33							33		33	33	33							33	Specialty																								
H9313	007	0	1	02	01	H9313_007_0	8	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00		90.00	270.00	180.00							90.00			
H9313	012	1	1	02	01	H9313_012_1	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		3.00	8.00	5.00							4.00	1	1	
H9313	012	1	1	02	01	H9313_012_1	6	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00	30.00							15.00		10.00	30.00	20.00							15.00	1	1	
H9313	012	1	1	02	01	H9313_012_1	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H9313	012	1	1	02	01	H9313_012_1	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H9313	012	1	1	02	01	H9313_012_1	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		3.00	8.00	5.00							4.00			
H9313	012	1	1	02	01	H9313_012_1	6	5	4	1	Specialty Tier	101101	1	1	2	Specialty Tier	111100000010111000000	30	90	60							30		30	90	60							34	1	Specialty Tier	1	Specialty Tier	33	33	33							33		33	33	33							33	Specialty Tier																								
H9313	012	1	1	02	01	H9313_012_1	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00		90.00	270.00	180.00							90.00			
H9313	012	1	1	02	01	H9313_012_1	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	50.00	150.00	100.00							50.00		50.00	150.00	100.00							50.00			
H9313	012	1	1	02	01	H9313_012_1	6	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00	30.00							15.00		10.00	30.00	20.00							15.00			
H9313	012	1	1	02	01	H9313_012_1	6	5	4	3	Specialty Tier	101101	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H9313	012	2	1	02	01	H9313_012_2	6	5	4	1	Specialty Tier	101101	1	1	2	Specialty Tier	111100000010111000000	30	90	60							30		30	90	60							34	1	Specialty Tier	1	Specialty Tier	33	33	33							33		33	33	33							33	Specialty Tier																								
H9313	012	2	1	02	01	H9313_012_2	6	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		3.00	8.00	5.00							4.00	1	1	
H9313	012	2	1	02	01	H9313_012_2	6	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00	30.00							15.00		10.00	30.00	20.00							15.00	1	1	
H9313	012	2	1	02	01	H9313_012_2	6	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H9313	012	2	1	02	01	H9313_012_2	6	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
H9313	012	2	1	02	01	H9313_012_2	6	5	4	3	Specialty Tier	101101	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
H9313	012	2	1	02	01	H9313_012_2	6	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		3.00	8.00	5.00							4.00			
H9313	012	2	1	02	01	H9313_012_2	6	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00	30.00							15.00		10.00	30.00	20.00							15.00			
H9313	012	2	1	02	01	H9313_012_2	6	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	50.00	150.00	100.00							50.00		50.00	150.00	100.00							50.00			
H9313	012	2	1	02	01	H9313_012_2	6	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010111000000	30	90	60							30		30	90	60							34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00	180.00							90.00		90.00	270.00	180.00							90.00			
H9385	002	0	1	01	01	H9385_002_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
H9385	002	0	1	01	01	H9385_002_0	6	2	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	31	90								31			90								31	2	Brand	2	Brand																						Brand	28.00	84.00								28.00			56.00								28.00			
H9385	002	0	1	01	01	H9385_002_0	6	3	4	3	Specialty	000010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
H9385	002	0	1	01	01	H9385_002_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	31	90								31			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00	1	1	
H9385	002	0	1	01	01	H9385_002_0	6	2	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
H9385	002	0	1	01	01	H9385_002_0	6	3	4	1	Specialty	000010	1	1	1	Specialty	110000000010000000000	31									31											31		Specialty	1	Specialty	25									25											25	Specialty																								
H9452	002	0	1	09	04	H9452_002_0	13	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
H9452	002	0	1	09	04	H9452_002_0	13	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	44.00	132.00								44.00						110.00			132.00		44.00			
H9452	002	0	1	09	04	H9452_002_0	13	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
H9452	002	0	1	09	04	H9452_002_0	13	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
H9452	002	0	1	09	04	H9452_002_0	13	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
H9452	002	0	1	09	04	H9452_002_0	13	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00	1	1	
H9452	002	0	1	09	04	H9452_002_0	13	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
H9452	002	0	1	09	04	H9452_002_0	13	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
H9452	002	0	1	09	04	H9452_002_0	13	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
H9452	002	0	1	09	04	H9452_002_0	13	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
H9503	001	0	1	04	01	H9503_001_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H9503	001	0	1	04	01	H9503_001_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H9503	001	0	1	04	01	H9503_001_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H9503	001	0	1	04	01	H9503_001_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H9503	001	0	1	04	01	H9503_001_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H9503	001	0	1	04	01	H9503_001_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H9503	001	0	1	04	01	H9503_001_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H9503	001	0	1	04	01	H9503_001_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H9503	003	0	1	04	01	H9503_003_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
H9503	003	0	1	04	01	H9503_003_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
H9503	003	0	1	04	01	H9503_003_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
H9503	003	0	1	04	01	H9503_003_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
H9503	003	0	1	04	01	H9503_003_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
H9503	003	0	1	04	01	H9503_003_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
H9503	003	0	1	04	01	H9503_003_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
H9503	003	0	1	04	01	H9503_003_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00			
H9519	001	0	1	09	04	H9519_001_0	6	4	4	3	Specialty Tier 4	001001	1	1	2	Specialty Tier 4																								Specialty Tier 4		Specialty Tier 4																						Specialty Tier 4																						2		
H9519	001	0	1	09	04	H9519_001_0	6	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H9519	001	0	1	09	04	H9519_001_0	6	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H9519	001	0	1	09	04	H9519_001_0	6	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00	1	2	10001000
H9519	001	0	1	09	04	H9519_001_0	6	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H9519	001	0	1	09	04	H9519_001_0	6	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00											70.00			
H9519	001	0	1	09	04	H9519_001_0	6	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00			
H9519	001	0	1	09	04	H9519_001_0	6	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	40.00	120.00								40.00			100.00								40.00			
H9519	003	0	1	09	04	H9519_003_0	9	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H9519	003	0	1	09	04	H9519_003_0	9	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H9519	003	0	1	09	04	H9519_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																						2		
H9519	003	0	1	09	04	H9519_003_0	9	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00	1	2	10001000
H9519	003	0	1	09	04	H9519_003_0	9	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								34	1	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00			20.00								8.00			
H9519	003	0	1	09	04	H9519_003_0	9	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								34	1	Tier 2	2	Tier 2																						Tier 2	45.00	135.00								45.00			112.50								45.00			
H9519	003	0	1	09	04	H9519_003_0	9	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010000000000	30	90								30											34	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00											75.00			
H9519	003	0	1	09	04	H9519_003_0	9	4	4	1	Specialty Tier 4	001001	1	1	2	Specialty Tier 4	110000000010000000000	30									30											34		Specialty Tier 4	1	Specialty Tier 4	33									33											33	Specialty Tier 4																								
H9572	001	1	1	04	01	H9572_001_1	8	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H9572	001	1	1	04	01	H9572_001_1	8	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H9572	001	1	1	04	01	H9572_001_1	8	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00					5.00	12.50		5.00	15.00		5.00			
H9572	001	1	1	04	01	H9572_001_1	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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			
H9572	001	1	1	04	01	H9572_001_1	8	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				95.00	237.50		95.00	285.00		95.00					95.00	237.50		95.00	285.00		95.00			
H9572	001	2	1	04	01	H9572_001_2	7	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H9572	001	2	1	04	01	H9572_001_2	7	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				95.00	237.50		95.00	285.00		95.00					95.00	237.50		95.00	285.00		95.00			
H9572	001	2	1	04	01	H9572_001_2	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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			
H9572	001	2	1	04	01	H9572_001_2	7	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00					5.00	12.50		5.00	15.00		5.00			
H9572	001	2	1	04	01	H9572_001_2	7	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H9572	001	3	1	04	01	H9572_001_3	7	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00					5.00	12.50		5.00	15.00		5.00			
H9572	001	3	1	04	01	H9572_001_3	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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			
H9572	001	3	1	04	01	H9572_001_3	7	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				95.00	237.50		95.00	285.00		95.00					95.00	237.50		95.00	285.00		95.00			
H9572	001	3	1	04	01	H9572_001_3	7	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H9572	001	3	1	04	01	H9572_001_3	7	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H9572	001	4	1	04	01	H9572_001_4	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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			
H9572	001	4	1	04	01	H9572_001_4	7	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H9572	001	4	1	04	01	H9572_001_4	7	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				95.00	237.50		95.00	285.00		95.00					95.00	237.50		95.00	285.00		95.00			
H9572	001	4	1	04	01	H9572_001_4	7	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00					5.00	12.50		5.00	15.00		5.00			
H9572	001	4	1	04	01	H9572_001_4	7	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H9572	001	5	1	04	01	H9572_001_5	7	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00					5.00	12.50		5.00	15.00		5.00			
H9572	001	5	1	04	01	H9572_001_5	7	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H9572	001	5	1	04	01	H9572_001_5	7	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H9572	001	5	1	04	01	H9572_001_5	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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			
H9572	001	5	1	04	01	H9572_001_5	7	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				95.00	237.50		95.00	285.00		95.00					95.00	237.50		95.00	285.00		95.00			
H9572	001	6	1	04	01	H9572_001_6	8	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00					5.00	12.50		5.00	15.00		5.00			
H9572	001	6	1	04	01	H9572_001_6	8	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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			
H9572	001	6	1	04	01	H9572_001_6	8	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				95.00	237.50		95.00	285.00		95.00					95.00	237.50		95.00	285.00		95.00			
H9572	001	6	1	04	01	H9572_001_6	8	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
H9572	001	6	1	04	01	H9572_001_6	8	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
H9615	002	0	1	04	01	H9615_002_0	11	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	9.00	27.00								9.00		18.00	18.00								9.00			
H9615	002	0	1	04	01	H9615_002_0	11	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00		60.00	60.00								30.00			
H9615	002	0	1	04	01	H9615_002_0	11	5	4	3	Tier 5	100100	1	2	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
H9615	002	0	1	04	01	H9615_002_0	11	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H9615	002	0	1	04	01	H9615_002_0	11	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H9615	002	0	1	04	01	H9615_002_0	11	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H9615	002	0	1	04	01	H9615_002_0	11	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	9.00	27.00								9.00		18.00	18.00								9.00	1	1	
H9615	002	0	1	04	01	H9615_002_0	11	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H9615	002	0	1	04	01	H9615_002_0	11	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9615	002	0	1	04	01	H9615_002_0	11	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00		170.00	170.00								85.00			
H9615	004	0	1	04	01	H9615_004_0	10	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	9.00	27.00								9.00		18.00	18.00								9.00			
H9615	004	0	1	04	01	H9615_004_0	10	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
H9615	004	0	1	04	01	H9615_004_0	10	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
H9615	004	0	1	04	01	H9615_004_0	10	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
H9615	004	0	1	04	01	H9615_004_0	10	5	4	3	Tier 5	100100	1	2	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
H9615	004	0	1	04	01	H9615_004_0	10	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H9615	004	0	1	04	01	H9615_004_0	10	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9615	004	0	1	04	01	H9615_004_0	10	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00		170.00	170.00								85.00			
H9615	004	0	1	04	01	H9615_004_0	10	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00		60.00	60.00								30.00			
H9615	004	0	1	04	01	H9615_004_0	10	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	9.00	27.00								9.00		18.00	18.00								9.00	1	1	
H9670	001	0	1	04	01	H9670_001_0	6	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H9670	001	0	1	04	01	H9670_001_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H9670	001	0	1	04	01	H9670_001_0	6	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
H9670	001	0	1	04	01	H9670_001_0	6	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand																								Tier 3 - Non-Preferred Brand		Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																						2		
H9670	001	0	1	04	01	H9670_001_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																						2		
H9670	001	0	1	04	01	H9670_001_0	6	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H9670	001	0	1	04	01	H9670_001_0	6	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H9670	001	0	1	04	01	H9670_001_0	6	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	85.00	255.00								85.00			212.50								85.00			
H9670	002	0	1	04	01	H9670_002_0	6	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H9670	002	0	1	04	01	H9670_002_0	6	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	30.00	90.00								30.00			75.00								30.00			
H9670	002	0	1	04	01	H9670_002_0	6	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
H9670	002	0	1	04	01	H9670_002_0	6	3	4	3	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand																								Tier 3 - Non-Preferred Brand		Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand																						2		
H9670	002	0	1	04	01	H9670_002_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																						2		
H9670	002	0	1	04	01	H9670_002_0	6	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00	1	1	
H9670	002	0	1	04	01	H9670_002_0	6	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H9670	002	0	1	04	01	H9670_002_0	6	3	4	1	Tier 3 - Non-Preferred Brand	100000	1	2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	85.00	255.00								85.00			212.50								85.00			
H9670	003	0	1	04	01	H9670_003_0	3	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H9670	003	0	1	04	01	H9670_003_0	3	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H9670	003	0	1	04	01	H9670_003_0	3	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H9670	003	0	1	04	01	H9670_003_0	3	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H9670	004	0	1	04	01	H9670_004_0	4	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
H9670	004	0	1	04	01	H9670_004_0	4	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
H9670	004	0	1	04	01	H9670_004_0	4	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
H9670	004	0	1	04	01	H9670_004_0	4	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
H9720	009	0	1	09	04	H9720_009_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9720	009	0	1	09	04	H9720_009_0	7	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00		75.00	150.00								75.00			
H9720	009	0	1	09	04	H9720_009_0	7	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	45.00	135.00								45.00		45.00	90.00								45.00			
H9720	009	0	1	09	04	H9720_009_0	7	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H9720	011	0	1	09	04	H9720_011_0	5	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H9720	011	0	1	09	04	H9720_011_0	5	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9720	011	0	1	09	04	H9720_011_0	5	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H9720	011	0	1	09	04	H9720_011_0	5	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H9720	026	0	1	09	04	H9720_026_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9720	026	0	1	09	04	H9720_026_0	7	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00		75.00	150.00								75.00			
H9720	026	0	1	09	04	H9720_026_0	7	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	45.00	135.00								45.00		45.00	90.00								45.00			
H9720	026	0	1	09	04	H9720_026_0	7	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H9720	039	0	1	09	04	H9720_039_0	7	1	4	1	Tier 1	010010	3	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00		0.00	0.00								0.00			
H9720	039	0	1	09	04	H9720_039_0	7	2	4	1	Tier2	010001	3	2	2	Tier2	111000000010110000000	30	90								30		30	90								31	1	Tier2	2	Tier2																						Tier2	39.00	117.00								39.00		39.00	78.00								39.00			
H9720	039	0	1	09	04	H9720_039_0	7	3	4	1	Tier 3	010100	3	2	1	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00		69.00	138.00								69.00			
H9720	039	0	1	09	04	H9720_039_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9779	001	0	1	04	01	H9779_001_0	11	6	4	3	Specialty	010010	1	1	2																																																																							2		
H9779	001	0	1	04	01	H9779_001_0	11	5	4	3	Non-Preferred Brand	100000	1	2	1																																																																							2		
H9779	001	0	1	04	01	H9779_001_0	11	4	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
H9779	001	0	1	04	01	H9779_001_0	11	3	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic																								Non-Preferred Generic		Non-Preferred Generic																						Non-Preferred Generic																						2		
H9779	001	0	1	04	01	H9779_001_0	11	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00	1	1	
H9779	001	0	1	04	01	H9779_001_0	11	6	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
H9779	001	0	1	04	01	H9779_001_0	11	5	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00			150.00								50.00			
H9779	001	0	1	04	01	H9779_001_0	11	4	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	25.00	75.00								25.00			75.00								25.00			
H9779	001	0	1	04	01	H9779_001_0	11	3	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	12.00	36.00								12.00			36.00								12.00			
H9779	001	0	1	04	01	H9779_001_0	11	2	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
H9779	001	0	1	04	01	H9779_001_0	11	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	0.00	0.00								0.00			0.00								0.00			
H9779	001	0	1	04	01	H9779_001_0	11	2	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00	1	1	
H9793	001	0	1	09	04	H9793_001_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
H9793	001	0	1	09	04	H9793_001_0	6	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	42.00	126.00								42.00		105.00	105.00								42.00			
H9793	001	0	1	09	04	H9793_001_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
H9793	001	0	1	09	04	H9793_001_0	6	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	2	Specialty	1	Specialty	33	33								33		33	33								33	Specialty																								
H9847	001	0	1	04	01	H9847_001_0	14	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
H9847	001	0	1	04	01	H9847_001_0	14	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	33.00	99.00								33.00			82.50								33.00			
H9847	001	0	1	04	01	H9847_001_0	14	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	63.00	189.00								63.00			189.00								63.00			
H9847	001	0	1	04	01	H9847_001_0	14	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H9847	003	0	1	04	01	H9847_003_0	11	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
H9847	003	0	1	04	01	H9847_003_0	11	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
H9847	003	0	1	04	01	H9847_003_0	11	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			87.50								35.00			
H9847	003	0	1	04	01	H9847_003_0	11	3	4	1	Non-Preferred Generic/Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	2	Non-Preferred Generic/Non-Preferred Brand																						Non-Preferred Generic/Non-Preferred Brand	68.00	204.00								68.00			204.00								68.00			
H9859	002	0	1	01	01	H9859_002_0	7	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9859	002	0	1	01	01	H9859_002_0	7	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H9859	002	0	1	01	01	H9859_002_0	7	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	90.00	270.00								90.00		180.00	180.00								90.00			
H9859	002	0	1	01	01	H9859_002_0	7	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00		70.00	70.00								35.00			
H9859	002	0	1	01	01	H9859_002_0	7	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00		20.00	20.00								10.00			
H9859	004	0	1	01	01	H9859_004_0	9	5	4	1	Tier 5	100100	1	2	2	Tier 5	111000000010110000000	34	90								34		34	90								31	2	Tier 5	1	Tier 5	80	80								80		80	80								80	Tier 5																								
H9859	004	0	1	01	01	H9859_004_0	9	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010110000000	34	90								34		34	90								31	2	Tier 4	1	Tier 4	33	33								33		33	33								33	Tier 4																								
H9859	004	0	1	01	01	H9859_004_0	9	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000010110000000	34	90								34		34	90								31	2	Tier 3	2	Tier 3																						Tier 3	90.00	270.00								90.00		180.00	180.00								90.00			
H9859	004	0	1	01	01	H9859_004_0	9	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010110000000	34	90								34		34	90								31	2	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00		66.00	66.00								33.00			
H9859	004	0	1	01	01	H9859_004_0	9	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	34	90								34		34	90								31	2	Tier 1	2	Tier 1																						Tier 1	10.00	30.00								10.00		20.00	20.00								10.00			
H9988	002	0	1	04	01	H9988_002_0	6	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H9988	002	0	1	04	01	H9988_002_0	6	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
H9988	002	0	1	04	01	H9988_002_0	6	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
H9988	004	0	1	04	01	H9988_004_0	7	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
H9988	004	0	1	04	01	H9988_004_0	7	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
H9988	004	0	1	04	01	H9988_004_0	7	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
R3175	001	0	1	31	11	R3175_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
R3175	001	0	1	31	11	R3175_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
R3175	001	0	1	31	11	R3175_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
R3175	001	0	1	31	11	R3175_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
R3175	004	0	1	31	11	R3175_004_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
R3175	004	0	1	31	11	R3175_004_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
R3175	004	0	1	31	11	R3175_004_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
R3175	004	0	1	31	11	R3175_004_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
R3332	001	0	1	31	11	R3332_001_0	6	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
R3332	001	0	1	31	11	R3332_001_0	6	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	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			
R3332	001	0	1	31	11	R3332_001_0	6	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	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			
R3332	001	0	1	31	11	R3332_001_0	6	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
R3444	008	0	1	31	11	R3444_008_0	8	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R3444	008	0	1	31	11	R3444_008_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R3444	008	0	1	31	11	R3444_008_0	8	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	0.00	0.00								0.00		0.00	0.00								0.00			
R3444	008	0	1	31	11	R3444_008_0	8	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R3444	009	0	1	31	11	R3444_009_0	10	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R3444	009	0	1	31	11	R3444_009_0	10	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R3444	009	0	1	31	11	R3444_009_0	10	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R3444	009	0	1	31	11	R3444_009_0	10	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00			
R3444	010	0	1	31	11	R3444_010_0	8	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R3444	010	0	1	31	11	R3444_010_0	8	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R3444	010	0	1	31	11	R3444_010_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R3444	010	0	1	31	11	R3444_010_0	8	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00			
R3444	011	0	1	31	11	R3444_011_0	9	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R3444	011	0	1	31	11	R3444_011_0	9	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R3444	011	0	1	31	11	R3444_011_0	9	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	40.00	120.00								40.00		40.00	100.00								40.00			
R3444	011	0	1	31	11	R3444_011_0	9	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R3444	012	0	1	31	11	R3444_012_0	6	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	36.00	108.00								36.00		36.00	90.00								36.00			
R3444	012	0	1	31	11	R3444_012_0	6	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R3444	012	0	1	31	11	R3444_012_0	6	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R3444	012	0	1	31	11	R3444_012_0	6	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R3444	020	0	1	31	11	R3444_020_0	4	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R3444	020	0	1	31	11	R3444_020_0	4	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	25	25								25		25	25								25	Formulary Specialty																								
R3444	020	0	1	31	11	R3444_020_0	4	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R3444	020	0	1	31	11	R3444_020_0	4	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R5287	001	0	1	31	11	R5287_001_0	6	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
R5287	001	0	1	31	11	R5287_001_0	6	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
R5287	001	0	1	31	11	R5287_001_0	6	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
R5287	001	0	1	31	11	R5287_001_0	6	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
R5342	001	0	1	31	11	R5342_001_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						12.00			18.00		6.00			
R5342	001	0	1	31	11	R5342_001_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						116.00			126.00		42.00			
R5342	001	0	1	31	11	R5342_001_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
R5342	001	0	1	31	11	R5342_001_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
R5342	004	0	1	31	11	R5342_004_0	5	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						125.00			135.00		45.00			
R5342	004	0	1	31	11	R5342_004_0	5	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
R5342	004	0	1	31	11	R5342_004_0	5	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						245.00			255.00		85.00			
R5342	004	0	1	31	11	R5342_004_0	5	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
R5566	005	0	1	31	11	R5566_005_0	4	1	2	1	Level 1: Covered Generic	010000		2	2	Level 1: Covered Generic	111000000010010000000	31	90								31			90								31	1	Level 1: Covered Generic	1	Level 1: Covered Generic	13	13								13			13								13	Level 1: Covered Generic																								
R5566	005	0	1	31	11	R5566_005_0	4	2	2	1	Level 2: Covered Preferred Brand	000001		2	2	Level 2: Covered Preferred Brand	111000000010010000000	31	90								31			90								31	1	Level 2: Covered Preferred Brand	1	Level 2: Covered Preferred Brand	23	23								23			23								23	Level 2: Covered Preferred Brand																								
R5566	005	0	1	31	11	R5566_005_0	4	3	2	1	Level 3: Covered Brand	100000		2	1	Level 3: Covered Brand	111000000010010000000	31	90								31			90								31	1	Level 3: Covered Brand	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																								
R5566	005	0	1	31	11	R5566_005_0	4	4	2	1	Covered Specialty	110011		1	2	Covered Specialty	111000000010010000000	31	90								31			90								31	1	Covered Specialty	1	Covered Specialty	25	25								25			25								25	Covered Specialty																								
R5674	001	0	1	31	11	R5674_001_0	13	3	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	110000000010000000000	30									30											31		Non-Preferred	2	Non-Preferred																						Non-Preferred	85.00									85.00											85.00			
R5674	001	0	1	31	11	R5674_001_0	13	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
R5674	001	0	1	31	11	R5674_001_0	13	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00			80.00								40.00			
R5674	001	0	1	31	11	R5674_001_0	13	1	4	1	Preferred Generic/Some Brand Maintenance	001001	1	2	2	Preferred Generic/Some Brand Maintenance	111000000010010000000	30	90								30			90								31	1	Preferred Generic/Some Brand Maintenance	2	Preferred Generic/Some Brand Maintenance																						Preferred Generic/Some Brand Maintenance	10.00	30.00								10.00			20.00								10.00			
R5826	002	0	1	31	11	R5826_002_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	002	0	1	31	11	R5826_002_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	002	0	1	31	11	R5826_002_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	002	0	1	31	11	R5826_002_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
R5826	002	0	1	31	11	R5826_002_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00					85.00	212.50		85.00	255.00		85.00	1	2	10000000
R5826	002	0	1	31	11	R5826_002_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00					85.00	212.50		85.00	255.00		85.00			
R5826	002	0	1	31	11	R5826_002_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	002	0	1	31	11	R5826_002_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
R5826	003	0	1	31	11	R5826_003_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	003	0	1	31	11	R5826_003_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	003	0	1	31	11	R5826_003_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	003	0	1	31	11	R5826_003_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
R5826	003	0	1	31	11	R5826_003_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00					85.00	212.50		85.00	255.00		85.00			
R5826	003	0	1	31	11	R5826_003_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	85.00	255.00								85.00					85.00	212.50		85.00	255.00		85.00	1	2	10000000
R5826	003	0	1	31	11	R5826_003_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	003	0	1	31	11	R5826_003_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
R5826	004	0	1	31	11	R5826_004_0	4	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	004	0	1	31	11	R5826_004_0	4	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	84.00	252.00								84.00					84.00	210.00		84.00	252.00		84.00			
R5826	004	0	1	31	11	R5826_004_0	4	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	004	0	1	31	11	R5826_004_0	4	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
R5826	004	0	1	31	11	R5826_004_0	4	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
R5826	004	0	1	31	11	R5826_004_0	4	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic / Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic / Preferred Brand	2	Non-Preferred Generic / Preferred Brand																						Non-Preferred Generic / Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	004	0	1	31	11	R5826_004_0	4	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	84.00	252.00								84.00					84.00	210.00		84.00	252.00		84.00	1	2	10000000
R5826	004	0	1	31	11	R5826_004_0	4	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	005	0	1	31	11	R5826_005_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	005	0	1	31	11	R5826_005_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
R5826	005	0	1	31	11	R5826_005_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	005	0	1	31	11	R5826_005_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
R5826	005	0	1	31	11	R5826_005_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	005	0	1	31	11	R5826_005_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
R5826	005	0	1	31	11	R5826_005_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	006	0	1	31	11	R5826_006_0	6	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	006	0	1	31	11	R5826_006_0	6	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
R5826	006	0	1	31	11	R5826_006_0	6	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	006	0	1	31	11	R5826_006_0	6	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
R5826	006	0	1	31	11	R5826_006_0	6	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
R5826	006	0	1	31	11	R5826_006_0	6	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	006	0	1	31	11	R5826_006_0	6	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
R5826	006	0	1	31	11	R5826_006_0	6	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	007	0	1	31	11	R5826_007_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
R5826	007	0	1	31	11	R5826_007_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/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	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	82.00	246.00								82.00					82.00	205.00		82.00	246.00		82.00			
R5826	007	0	1	31	11	R5826_007_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	007	0	1	31	11	R5826_007_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
R5826	007	0	1	31	11	R5826_007_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	40.00	120.00								40.00					40.00	100.00		40.00	120.00		40.00	1	2	10001000
R5826	007	0	1	31	11	R5826_007_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	82.00	246.00								82.00					82.00	205.00		82.00	246.00		82.00	1	2	10000000
R5826	007	0	1	31	11	R5826_007_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	008	0	1	31	11	R5826_008_0	8	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00			
R5826	008	0	1	31	11	R5826_008_0	8	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	008	0	1	31	11	R5826_008_0	8	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
R5826	008	0	1	31	11	R5826_008_0	8	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	008	0	1	31	11	R5826_008_0	8	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00					0.00	0.00		10.00	30.00		10.00	1	2	00001000
R5826	008	0	1	31	11	R5826_008_0	8	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/ Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/ Preferred Brand	2	Non-Preferred Generic/ Preferred Brand																						Non-Preferred Generic/ Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	008	0	1	31	11	R5826_008_0	8	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
R5826	008	0	1	31	11	R5826_008_0	8	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	011	0	1	31	11	R5826_011_0	3	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	011	0	1	31	11	R5826_011_0	3	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
R5826	011	0	1	31	11	R5826_011_0	3	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	011	0	1	31	11	R5826_011_0	3	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00	1	2	00001000
R5826	011	0	1	31	11	R5826_011_0	3	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	011	0	1	31	11	R5826_011_0	3	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
R5826	011	0	1	31	11	R5826_011_0	3	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00					0.00	0.00		8.00	24.00		8.00			
R5826	011	0	1	31	11	R5826_011_0	3	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	012	0	1	31	11	R5826_012_0	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	012	0	1	31	11	R5826_012_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
R5826	012	0	1	31	11	R5826_012_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00	1	2	10001000
R5826	012	0	1	31	11	R5826_012_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
R5826	012	0	1	31	11	R5826_012_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	012	0	1	31	11	R5826_012_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
R5826	012	0	1	31	11	R5826_012_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	44.00	132.00								44.00					44.00	110.00		44.00	132.00		44.00			
R5826	012	0	1	31	11	R5826_012_0	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	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	7	4	4	3	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																						1	2	10001000
R5826	014	0	1	31	11	R5826_014_0	7	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00			
R5826	014	0	1	31	11	R5826_014_0	7	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00			
R5826	014	0	1	31	11	R5826_014_0	7	4	4	1	Specialty	110110	1	1	2	Specialty	110000000010000100100	30									30					30			30			34		Specialty	1	Specialty	33									33					33			33			33	Specialty																								
R5826	014	0	1	31	11	R5826_014_0	7	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	111000000010000110110	30	90								30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00					0.00	0.00		7.00	21.00		7.00	1	2	00001000
R5826	014	0	1	31	11	R5826_014_0	7	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand	42.00	126.00								42.00					42.00	105.00		42.00	126.00		42.00	1	2	10001000
R5826	014	0	1	31	11	R5826_014_0	7	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	111000000010000110110	30	90								30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	80.00	240.00								80.00					80.00	200.00		80.00	240.00		80.00	1	2	10000000
R5941	001	0	1	31	11	R5941_001_0	10	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
R5941	001	0	1	31	11	R5941_001_0	10	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
R5941	001	0	1	31	11	R5941_001_0	10	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
R5941	001	0	1	31	11	R5941_001_0	10	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
R5941	001	0	1	31	11	R5941_001_0	10	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
R5941	001	0	1	31	11	R5941_001_0	10	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
R5941	001	0	1	31	11	R5941_001_0	10	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
R5941	001	0	1	31	11	R5941_001_0	10	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
R5941	001	0	1	31	11	R5941_001_0	10	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
R5941	001	0	1	31	11	R5941_001_0	10	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
R5941	003	0	1	31	11	R5941_003_0	11	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
R5941	003	0	1	31	11	R5941_003_0	11	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
R5941	003	0	1	31	11	R5941_003_0	11	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
R5941	003	0	1	31	11	R5941_003_0	11	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
R5941	003	0	1	31	11	R5941_003_0	11	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
R5941	003	0	1	31	11	R5941_003_0	11	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
R5941	003	0	1	31	11	R5941_003_0	11	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
R5941	003	0	1	31	11	R5941_003_0	11	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
R5941	003	0	1	31	11	R5941_003_0	11	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
R5941	003	0	1	31	11	R5941_003_0	11	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
R5941	008	0	1	31	11	R5941_008_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
R5941	008	0	1	31	11	R5941_008_0	9	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
R5941	008	0	1	31	11	R5941_008_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
R5941	008	0	1	31	11	R5941_008_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
R5941	008	0	1	31	11	R5941_008_0	9	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
R5941	008	0	1	31	11	R5941_008_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
R5941	008	0	1	31	11	R5941_008_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
R5941	008	0	1	31	11	R5941_008_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
R5941	008	0	1	31	11	R5941_008_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
R5941	008	0	1	31	11	R5941_008_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
R5941	009	0	1	31	11	R5941_009_0	8	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
R5941	009	0	1	31	11	R5941_009_0	8	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
R5941	009	0	1	31	11	R5941_009_0	8	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
R5941	009	0	1	31	11	R5941_009_0	8	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
R5941	009	0	1	31	11	R5941_009_0	8	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
R5941	009	0	1	31	11	R5941_009_0	8	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
R5941	009	0	1	31	11	R5941_009_0	8	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
R5941	009	0	1	31	11	R5941_009_0	8	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
R5941	009	0	1	31	11	R5941_009_0	8	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
R5941	009	0	1	31	11	R5941_009_0	8	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
R6801	008	0	1	31	11	R6801_008_0	7	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R6801	008	0	1	31	11	R6801_008_0	7	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	43.00	129.00								43.00		43.00	107.50								43.00			
R6801	008	0	1	31	11	R6801_008_0	7	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R6801	008	0	1	31	11	R6801_008_0	7	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R6801	009	0	1	31	11	R6801_009_0	10	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R6801	009	0	1	31	11	R6801_009_0	10	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R6801	009	0	1	31	11	R6801_009_0	10	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R6801	009	0	1	31	11	R6801_009_0	10	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00			
R6801	010	0	1	31	11	R6801_010_0	7	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R6801	010	0	1	31	11	R6801_010_0	7	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R6801	010	0	1	31	11	R6801_010_0	7	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R6801	010	0	1	31	11	R6801_010_0	7	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00			
R6801	011	0	1	31	11	R6801_011_0	8	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R6801	011	0	1	31	11	R6801_011_0	8	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R6801	011	0	1	31	11	R6801_011_0	8	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R6801	011	0	1	31	11	R6801_011_0	8	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R6801	012	0	1	31	11	R6801_012_0	6	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R6801	012	0	1	31	11	R6801_012_0	6	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R6801	012	0	1	31	11	R6801_012_0	6	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	39.00	117.00								39.00		39.00	97.50								39.00			
R6801	012	0	1	31	11	R6801_012_0	6	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R6801	020	0	1	31	11	R6801_020_0	4	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R6801	020	0	1	31	11	R6801_020_0	4	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R6801	020	0	1	31	11	R6801_020_0	4	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R6801	020	0	1	31	11	R6801_020_0	4	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	25	25								25		25	25								25	Formulary Specialty																								
R7444	001	0	1	31	11	R7444_001_0	4	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	5.00	15.00								5.00						10.00			15.00		5.00			
R7444	001	0	1	31	11	R7444_001_0	4	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
R7444	001	0	1	31	11	R7444_001_0	4	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						227.00			237.00		79.00			
R7444	001	0	1	31	11	R7444_001_0	4	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						113.00			123.00		41.00			
R9896	008	0	1	31	11	R9896_008_0	8	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	0.00	0.00								0.00		0.00	0.00								0.00			
R9896	008	0	1	31	11	R9896_008_0	8	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R9896	008	0	1	31	11	R9896_008_0	8	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R9896	008	0	1	31	11	R9896_008_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R9896	009	0	1	31	11	R9896_009_0	7	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00			
R9896	009	0	1	31	11	R9896_009_0	7	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R9896	009	0	1	31	11	R9896_009_0	7	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R9896	009	0	1	31	11	R9896_009_0	7	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R9896	010	0	1	31	11	R9896_010_0	8	1	4	1	Formulary Generic	010000	1	2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	4.00	12.00								4.00		4.00	10.00								4.00			
R9896	010	0	1	31	11	R9896_010_0	8	3	4	1	Formulary Non-Preferred Brand	100000	1	2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R9896	010	0	1	31	11	R9896_010_0	8	4	4	1	Formulary Specialty	010010	1	1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R9896	010	0	1	31	11	R9896_010_0	8	2	4	1	Formulary Preferred Brand	000001	1	2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R9896	012	0	1	31	11	R9896_012_0	7	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	33	33								33		33	33								33	Formulary Specialty																								
R9896	012	0	1	31	11	R9896_012_0	7	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R9896	012	0	1	31	11	R9896_012_0	7	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R9896	012	0	1	31	11	R9896_012_0	7	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	37.00	111.00								37.00		37.00	92.50								37.00			
R9896	020	0	1	31	11	R9896_020_0	3	3	3	1	Formulary Non-Preferred Brand	100000		2	1	Formulary Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Non-Preferred Brand	2	Formulary Non-Preferred Brand																						Formulary Non-Preferred Brand	95.00	285.00								95.00		95.00	237.50								95.00			
R9896	020	0	1	31	11	R9896_020_0	3	2	3	1	Formulary Preferred Brand	000001		2	2	Formulary Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Formulary Preferred Brand	2	Formulary Preferred Brand																						Formulary Preferred Brand	45.00	135.00								45.00		45.00	112.50								45.00			
R9896	020	0	1	31	11	R9896_020_0	3	1	3	1	Formulary Generic	010000		2	2	Formulary Generic	111000000010110000000	30	90								30		30	90								31	1	Formulary Generic	2	Formulary Generic																						Formulary Generic	9.00	27.00								9.00		9.00	22.50								9.00			
R9896	020	0	1	31	11	R9896_020_0	3	4	3	1	Formulary Specialty	010010		1	2	Formulary Specialty	111000000010110000000	30	90								30		30	90								31	1	Formulary Specialty	1	Formulary Specialty	25	25								25		25	25								25	Formulary Specialty																								
R9943	001	0	1	31	11	R9943_001_0	9	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
R9943	001	0	1	31	11	R9943_001_0	9	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
R9943	001	0	1	31	11	R9943_001_0	9	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
R9943	001	0	1	31	11	R9943_001_0	9	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
R9943	001	0	1	31	11	R9943_001_0	9	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
R9943	001	0	1	31	11	R9943_001_0	9	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
R9943	001	0	1	31	11	R9943_001_0	9	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
R9943	001	0	1	31	11	R9943_001_0	9	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
R9943	001	0	1	31	11	R9943_001_0	9	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
R9943	001	0	1	31	11	R9943_001_0	9	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
R9943	003	0	1	31	11	R9943_003_0	11	1	4	1	Preferred Generic Drugs	001000	3	2	2	Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
R9943	003	0	1	31	11	R9943_003_0	11	2	4	1	Preferred Brand  Certain Generic Drugs	010001	1	2	2	Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Preferred Brand  Certain Generic Drugs	2	Preferred Brand  Certain Generic Drugs																						Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
R9943	003	0	1	31	11	R9943_003_0	11	3	4	1	Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Non-Preferred Brand  Certain Generic Drugs	2	Non-Preferred Brand  Certain Generic Drugs																						Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
R9943	003	0	1	31	11	R9943_003_0	11	4	4	1	Non-Specialty Injectable Drugs	010010	1	2	2	Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Non-Specialty Injectable Drugs	1	Non-Specialty Injectable Drugs	33	33								33						33			33		33	Non-Specialty Injectable Drugs																								
R9943	003	0	1	31	11	R9943_003_0	11	5	4	3	Specialty Drugs	010010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
R9943	003	0	1	31	11	R9943_003_0	11	1	4	3	Preferred Generic Drugs	001000	3	2	2	Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Preferred Generic Drugs	2	Preferred Generic Drugs																						Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
R9943	003	0	1	31	11	R9943_003_0	11	2	4	3	Preferred Brand  Certain Generic Drugs	010001	1	2	2	Preferred Brand  Certain Generic Drugs																								Preferred Brand  Certain Generic Drugs		Preferred Brand  Certain Generic Drugs																						Preferred Brand  Certain Generic Drugs																						2		
R9943	003	0	1	31	11	R9943_003_0	11	3	4	3	Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Non-Preferred Brand  Certain Generic Drugs																								Non-Preferred Brand  Certain Generic Drugs		Non-Preferred Brand  Certain Generic Drugs																						Non-Preferred Brand  Certain Generic Drugs																						2		
R9943	003	0	1	31	11	R9943_003_0	11	4	4	3	Non-Specialty Injectable Drugs	010010	1	2	2	Non-Specialty Injectable Drugs																								Non-Specialty Injectable Drugs		Non-Specialty Injectable Drugs																						Non-Specialty Injectable Drugs																						2		
R9943	003	0	1	31	11	R9943_003_0	11	5	4	1	Specialty Drugs	010010	1	1	2	Specialty Drugs	110000000010000100100	30									30					30			30			34		Specialty Drugs	1	Specialty Drugs	33									33					33			33			33	Specialty Drugs																								
S0043	009	0		29	10	S0043_009_0	1	4	2	1	Specialty	010011		1	1	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S0043	009	0		29	10	S0043_009_0	1	2	2	1	Brand	000010		2	2	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	24.00	72.00								24.00			48.00								24.00			
S0043	009	0		29	10	S0043_009_0	1	3	2	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	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	1	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	5.00	15.00								5.00			10.00								5.00			
S0043	010	0		29	10	S0043_010_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00			
S0043	010	0		29	10	S0043_010_0	1	2	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
S0043	010	0		29	10	S0043_010_0	1	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	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	1	4	4	1	Specialty	010011	1	1	1	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S0043	013	0		29	10	S0043_013_0	3	4	4	3	Specialty	010011	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
S0043	013	0		29	10	S0043_013_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00			
S0043	013	0		29	10	S0043_013_0	3	2	4	1	Brand	000010	1	2	2	Brand	111000000010010000000	30	90								30			90								31	2	Brand	2	Brand																						Brand	25.00	75.00								25.00			50.00								25.00			
S0043	013	0		29	10	S0043_013_0	3	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	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	3	4	4	1	Specialty	010011	1	1	1	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S0043	013	0		29	10	S0043_013_0	3	3	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S0043	013	0		29	10	S0043_013_0	3	2	4	3	Brand	000010	1	2	2	Brand																								Brand		Brand																						Brand																						2		
S0043	013	0		29	10	S0043_013_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	2	Generic	2	Generic																						Generic	3.00	9.00								3.00			6.00								3.00	1	2	00001000
S0197	002	0		29	10	S0197_002_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S0197	002	0		29	10	S0197_002_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S0197	002	0		29	10	S0197_002_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S0197	002	0		29	10	S0197_002_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S0197	003	0		29	10	S0197_003_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S0197	003	0		29	10	S0197_003_0	2	3	3	1	Non-Preferred Generic and Brand	100100		2	1	Non-Preferred Generic and Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Brand	1	Non-Preferred Generic and Brand	50	50								50			50								50	Non-Preferred Generic and Brand																								
S0197	003	0		29	10	S0197_003_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	13.00	39.00								13.00			32.50								13.00			
S0197	003	0		29	10	S0197_003_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S0197	005	0		29	10	S0197_005_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S0197	005	0		29	10	S0197_005_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S0197	005	0		29	10	S0197_005_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S0197	005	0		29	10	S0197_005_0	2	5	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																						2		
S0197	005	0		29	10	S0197_005_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S0197	005	0		29	10	S0197_005_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S0197	005	0		29	10	S0197_005_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S0197	005	0		29	10	S0197_005_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S0197	005	0		29	10	S0197_005_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S0197	005	0		29	10	S0197_005_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S0655	002	0		29	10	S0655_002_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00	16.00							8.00		7.00	20.00	13.00							8.00			
S0655	002	0		29	10	S0655_002_0	2	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00	60.00							30.00		25.00	75.00	50.00							30.00			
S0655	002	0		29	10	S0655_002_0	2	3	4	1	Tier 3	000010	1	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	65.00	195.00	130.00							65.00		54.00	163.00	108.00							65.00			
S0655	002	0		29	10	S0655_002_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 4	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																								
S0655	003	0		29	10	S0655_003_0	2	3	4	3	Tier 3	000010	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S0655	003	0		29	10	S0655_003_0	2	2	4	3	Tier 2	010010	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S0655	003	0		29	10	S0655_003_0	2	1	4	3	Tier 1	010000	1	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00	16.00							8.00		7.00	20.00	13.00							8.00	1	1	
S0655	003	0		29	10	S0655_003_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 4	1	Tier 4	33	33	33							33		33	33	33							33	Tier 4																								
S0655	003	0		29	10	S0655_003_0	2	3	4	1	Tier 3	000010	1	2	1	Tier 3	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 3	2	Tier 3																						Tier 3	60.00	180.00	120.00							60.00		50.00	150.00	100.00							60.00			
S0655	003	0		29	10	S0655_003_0	2	2	4	1	Tier 2	010010	1	2	2	Tier 2	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00	50.00							25.00		21.00	63.00	42.00							25.00			
S0655	003	0		29	10	S0655_003_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111100000010111000000	30	90	60							30		30	90	60							31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00	16.00							8.00		7.00	20.00	13.00							8.00			
S0655	003	0		29	10	S0655_003_0	2	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S1030	001	0		29	10	S1030_001_0	2	3	4	1	Tier 3	000010	1	2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00								35.00		35.00	87.50								35.00			
S1030	001	0		29	10	S1030_001_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S1030	001	0		29	10	S1030_001_0	2	3	4	3	Tier 3	000010	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S1030	001	0		29	10	S1030_001_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S1030	001	0		29	10	S1030_001_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00	1	1	
S1030	001	0		29	10	S1030_001_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	2.00	6.00								2.00		2.00	5.00								2.00			
S1030	001	0		29	10	S1030_001_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	4.00	12.00								4.00		4.00	10.00								4.00			
S1030	001	0		29	10	S1030_001_0	2	5	4	3	Tier 5	100000	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S1030	001	0		29	10	S1030_001_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	180.00								60.00		60.00	150.00								60.00			
S1030	001	0		29	10	S1030_001_0	2	5	4	1	Tier 5	100000	1	1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	33	33								33		33	33								33	Tier 5																								
S1030	006	0		29	10	S1030_006_0	2	5	3	1	Tier 5	100000		1	2	Tier 5	111000000010110000000	30	90								30		30	90								31	1	Tier 5	1	Tier 5	25	25								25		25	25								25	Tier 5																								
S1030	006	0		29	10	S1030_006_0	2	4	3	1	Tier 4	100000		2	1	Tier 4	111000000010110000000	30	90								30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	180.00								60.00		60.00	180.00								60.00			
S1030	006	0		29	10	S1030_006_0	2	3	3	1	Tier 3	000010		2	2	Tier 3	111000000010110000000	30	90								30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00								35.00		35.00	105.00								35.00			
S1030	006	0		29	10	S1030_006_0	2	2	3	1	Tier 2	000100		2	2	Tier 2	111000000010110000000	30	90								30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2	5.00	15.00								5.00		5.00	15.00								5.00			
S1030	006	0		29	10	S1030_006_0	2	1	3	1	Tier 1	001000		2	2	Tier 1	111000000010110000000	30	90								30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00		3.00	9.00								3.00			
S2321	002	0		29	10	S2321_002_0	2	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00			
S2321	002	0		29	10	S2321_002_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S2321	002	0		29	10	S2321_002_0	2	5	4	3	Specialty	101101	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S2321	002	0		29	10	S2321_002_0	2	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			14.00								7.00	1	1	
S2321	002	0		29	10	S2321_002_0	2	5	4	1	Specialty	101101	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	1	Specialty	1	Specialty	30	30								30			30								30	Specialty																								
S2321	002	0		29	10	S2321_002_0	2	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00			140.00								70.00			
S2321	002	0		29	10	S2321_002_0	2	3	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00			70.00								35.00			
S2321	002	0		29	10	S2321_002_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			14.00								7.00			
S2321	002	0		29	10	S2321_002_0	2	3	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S2321	002	0		29	10	S2321_002_0	2	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111000000010010000000	30	90								30			90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	15.00	45.00								15.00			30.00								15.00	1	1	
S2468	001	0		29	10	S2468_001_0	2	4	4	1	Injectables	010010	1	2	1	Injectables	100011011010010000000				30	90		30	90		30			90								34	1	Injectables	1	Injectables				33	33		33	33		33			33								33	Injectables																								
S2468	001	0		29	10	S2468_001_0	2	5	4	1	Formulary Specialty (Unique High Cost Drugs)	010010	1	1	2	Formulary Specialty (Unique High Cost Drugs)	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Specialty (Unique High Cost Drugs)	1	Formulary Specialty (Unique High Cost Drugs)				33	33		33	33		33			33								33	Formulary Specialty (Unique High Cost Drugs)																								
S2468	001	0		29	10	S2468_001_0	2	3	4	1	Non-Preferred Brand	100010	1	2	2	Non-Preferred Brand	100011011010010000000				30	90		30	90		30			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	150.00		75.00	225.00		75.00			150.00								75.00			
S2468	001	0		29	10	S2468_001_0	2	2	4	1	Formulary Brand	010010	1	2	2	Formulary Brand	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Brand	2	Formulary Brand																						Formulary Brand				35.00	70.00		35.00	105.00		35.00			70.00								35.00			
S2468	001	0		29	10	S2468_001_0	2	1	4	1	Formulary Generic	010010	3	2	2	Formulary Generic	100011011010010000000				30	90		30	90		30			90								34	1	Formulary Generic	2	Formulary Generic																						Formulary Generic				9.00	18.00		9.00	27.00		9.00			18.00								9.00			
S2505	001	0		29	10	S2505_001_0	2	3	2	1	Tier 3 - Specialty	010010		1	2	Tier 3 - Specialty	110000000010100000000	30									30		30									31		Tier 3 - Specialty	1	Tier 3 - Specialty	25									25		25									25	Tier 3 - Specialty																								
S2505	001	0		29	10	S2505_001_0	2	4	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	100100		2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	110000000010100000000	30									30		30									31		Tier 4 - NonPreferred Brand/NonPreferred Generic	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	45									45		45									45	Tier 4 - NonPreferred Brand/NonPreferred Generic																								
S2505	001	0		29	10	S2505_001_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	110000000010100000000	30									30		30									31		Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00									5.00		5.00									5.00			
S2505	001	0		29	10	S2505_001_0	2	2	2	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31		Tier 2 - Preferred Brand	1	Tier 2 - Preferred Brand	20									20		20									20	Tier 2 - Preferred Brand																								
S2505	003	0		29	10	S2505_003_0	2	3	2	1	Tier 3 - Specialty	010010		1	2	Tier 3 - Specialty	110000000010100000000	30									30		30									31		Tier 3 - Specialty	1	Tier 3 - Specialty	25									25		25									25	Tier 3 - Specialty																								
S2505	003	0		29	10	S2505_003_0	2	4	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	100100		2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	110000000010100000000	30									30		30									31		Tier 4 - NonPreferred Brand/NonPreferred Generic	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	40									40		40									40	Tier 4 - NonPreferred Brand/NonPreferred Generic																								
S2505	003	0		29	10	S2505_003_0	2	2	2	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31		Tier 2 - Preferred Brand	1	Tier 2 - Preferred Brand	20									20		20									20	Tier 2 - Preferred Brand																								
S2505	003	0		29	10	S2505_003_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	110000000010100000000	30									30		30									31		Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00									5.00		5.00									5.00			
S2505	005	0		29	10	S2505_005_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	110000000010100000000	30									30		30									31		Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00									5.00		5.00									5.00			
S2505	005	0		29	10	S2505_005_0	2	3	2	1	Tier 3 - Specialty	010010		1	2	Tier 3 - Specialty	110000000010100000000	30									30		30									31		Tier 3 - Specialty	1	Tier 3 - Specialty	25									25		25									25	Tier 3 - Specialty																								
S2505	005	0		29	10	S2505_005_0	2	4	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	100100		2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	110000000010100000000	30									30		30									31		Tier 4 - NonPreferred Brand/NonPreferred Generic	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	50									50		50									50	Tier 4 - NonPreferred Brand/NonPreferred Generic																								
S2505	005	0		29	10	S2505_005_0	2	2	2	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31		Tier 2 - Preferred Brand	1	Tier 2 - Preferred Brand	20									20		20									20	Tier 2 - Preferred Brand																								
S2505	007	0		29	10	S2505_007_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	110000000010100000000	30									30		30									31		Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00									5.00		5.00									5.00			
S2505	007	0		29	10	S2505_007_0	2	2	2	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	110000000010100000000	30									30		30									31		Tier 2 - Preferred Brand	1	Tier 2 - Preferred Brand	20									20		20									20	Tier 2 - Preferred Brand																								
S2505	007	0		29	10	S2505_007_0	2	3	2	1	Tier 3 - Specialty	010010		1	2	Tier 3 - Specialty	110000000010100000000	30									30		30									31		Tier 3 - Specialty	1	Tier 3 - Specialty	25									25		25									25	Tier 3 - Specialty																								
S2505	007	0		29	10	S2505_007_0	2	4	2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	100100		2	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	110000000010100000000	30									30		30									31		Tier 4 - NonPreferred Brand/NonPreferred Generic	1	Tier 4 - NonPreferred Brand/NonPreferred Generic	50									50		50									50	Tier 4 - NonPreferred Brand/NonPreferred Generic																								
S2873	002	0		29	10	S2873_002_0	2	4	4	1	Specialty	100000	1	1	2	Specialty	111000000001110000000	31	93									10	31	93								31	1	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
S2873	002	0		29	10	S2873_002_0	2	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	93									10	31	93								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00									50.00	50.00	150.00								50.00			
S2873	002	0		29	10	S2873_002_0	2	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000001110000000	31	93									10	31	93								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00									30.00	30.00	90.00								30.00			
S2873	002	0		29	10	S2873_002_0	2	1	4	1	Generics	010000	1	2	2	Generics	111000000001110000000	31	93									10	31	93								31	1	Generics	2	Generics																						Generics	5.00	15.00									5.00	5.00	15.00								5.00			
S2873	003	0		29	10	S2873_003_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000001110000000	31	93									10	31	93								31	1	Generic	2	Generic																						Generic	1.00	3.00									1.00	1.00	3.00								1.00			
S2873	003	0		29	10	S2873_003_0	4	4	4	3	Specialty	100000	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S2873	003	0		29	10	S2873_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																						2		
S2873	003	0		29	10	S2873_003_0	4	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S2873	003	0		29	10	S2873_003_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000001110000000	31	93									10	31	93								31	1	Generic	2	Generic																						Generic	1.00	3.00									1.00	1.00	3.00								1.00	1	1	
S2873	003	0		29	10	S2873_003_0	4	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000001110000000	31	93									10	31	93								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	20.00	60.00									20.00	20.00	60.00								20.00			
S2873	003	0		29	10	S2873_003_0	4	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000001110000000	31	93									10	31	93								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	40.00	120.00									40.00	40.00	120.00								40.00			
S2873	003	0		29	10	S2873_003_0	4	4	4	1	Specialty	100000	1	1	2	Specialty	111000000001110000000	31	93									10	31	93								31	1	Specialty	1	Specialty	33	33									33	33	33								33	Specialty																								
S2874	001	0		29	10	S2874_001_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S2874	001	0		29	10	S2874_001_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S2874	001	0		29	10	S2874_001_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				42	42		47	47		42					42	42		42	42		42	Non-Preferred Brand																								
S2874	002	0		29	10	S2874_002_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S2874	002	0		29	10	S2874_002_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S2874	002	0		29	10	S2874_002_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S2874	002	0		29	10	S2874_002_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S2893	001	0		29	10	S2893_001_0	1	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010000010010	30	90								30						90			90		31	2	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00						187.50			225.00		75.00			
S2893	001	0		29	10	S2893_001_0	1	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010000010010	30	90								30						90			90		31	2	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00						87.50			105.00		35.00			
S2893	001	0		29	10	S2893_001_0	1	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						20.00			24.00		8.00			
S2893	001	0		29	10	S2893_001_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010000010010	30	90								30						90			90		31	2	Tier 4	1	Tier 4	33	33								33						33			33		33	Tier 4																								
S2893	003	0		29	10	S2893_003_0	1	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010000010010	30	90								30						90			90		31	2	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00						175.00			210.00		70.00			
S2893	003	0		29	10	S2893_003_0	1	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010000010010	30	90								30						90			90		31	2	Tier 2	2	Tier 2																						Tier 2	30.00	90.00								30.00						75.00			90.00		30.00			
S2893	003	0		29	10	S2893_003_0	1	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						20.00			24.00		8.00			
S2893	003	0		29	10	S2893_003_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010000010010	30	90								30						90			90		31	2	Tier 4	1	Tier 4	33	33								33						33			33		33	Tier 4																								
S2893	003	0		29	10	S2893_003_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S2893	003	0		29	10	S2893_003_0	1	3	4	3	Tier 3	100000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S2893	003	0		29	10	S2893_003_0	1	2	4	3	Tier 2	000001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S2893	003	0		29	10	S2893_003_0	1	1	4	3	Tier 1	010000	3	2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						20.00			24.00		8.00	1	1	
S2893	014	0		29	10	S2893_014_0	1	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010000010010	30	90								30						90			90		31	2	Tier 2	2	Tier 2																						Tier 2	25.00	75.00								25.00						62.50			75.00		25.00			
S2893	014	0		29	10	S2893_014_0	1	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010000010010	30	90								30						90			90		31	2	Tier 1	2	Tier 1																						Tier 1	8.00	24.00								8.00						20.00			24.00		8.00			
S2893	014	0		29	10	S2893_014_0	1	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010000010010	30	90								30						90			90		31	2	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00						162.50			195.00		65.00			
S2893	014	0		29	10	S2893_014_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010000010010	30	90								30						90			90		31	2	Tier 4	1	Tier 4	25	25								25						25			25		25	Tier 4																								
S3389	005	0		29	10	S3389_005_0	3	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
S3389	005	0		29	10	S3389_005_0	3	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
S3389	005	0		29	10	S3389_005_0	3	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
S3389	005	0		29	10	S3389_005_0	3	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
S3440	001	0		29	10	S3440_001_0	4	4	3	1	Tier 4	100001		1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	29	29								29			29								29	Tier 4																								
S3440	001	0		29	10	S3440_001_0	4	3	3	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
S3440	001	0		29	10	S3440_001_0	4	1	3	1	Tier 1	001001		2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	8.00	20.00								8.00			20.00								8.00			
S3440	001	0		29	10	S3440_001_0	4	2	3	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	45.00	112.50								45.00			112.50								45.00			
S3440	002	0		29	10	S3440_002_0	4	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
S3440	002	0		29	10	S3440_002_0	4	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	87.50								35.00			87.50								35.00			
S3440	002	0		29	10	S3440_002_0	4	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	150.00								60.00			150.00								60.00			
S3440	002	0		29	10	S3440_002_0	4	4	4	1	Tier 4	100001	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	2	Tier 4																						Tier 4	60.00	150.00								60.00			150.00								60.00			
S3521	003	0		29	10	S3521_003_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	30	90								30			90								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S3521	003	0		29	10	S3521_003_0	1	1	4	1	Tier 1	010000	3	2	2	Tier 1	111000000010010000000	30	90								30			90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	12.50								5.00			12.50								5.00			
S3521	003	0		29	10	S3521_003_0	1	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	30	90								30			90								31	1	Tier 2	2	Tier 2																						Tier 2	30.00	75.00								30.00			75.00								30.00			
S3521	003	0		29	10	S3521_003_0	1	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	30	90								30			90								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	187.50								75.00			187.50								75.00			
S4802	001	0		29	10	S4802_001_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	001	0		29	10	S4802_001_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	001	0		29	10	S4802_001_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	002	0		29	10	S4802_002_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	002	0		29	10	S4802_002_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	31.00	93.00									31.00		62.00								31.00			
S4802	002	0		29	10	S4802_002_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	003	0		29	10	S4802_003_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	003	0		29	10	S4802_003_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	29.00	87.00									29.00		58.00								29.00			
S4802	003	0		29	10	S4802_003_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	004	0		29	10	S4802_004_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	29.00	87.00									29.00		58.00								29.00			
S4802	004	0		29	10	S4802_004_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	004	0		29	10	S4802_004_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	005	0		29	10	S4802_005_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	005	0		29	10	S4802_005_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	005	0		29	10	S4802_005_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	31.00	93.00									31.00		62.00								31.00			
S4802	006	0		29	10	S4802_006_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	29.00	87.00									29.00		58.00								29.00			
S4802	006	0		29	10	S4802_006_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	006	0		29	10	S4802_006_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	007	0		29	10	S4802_007_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	007	0		29	10	S4802_007_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	007	0		29	10	S4802_007_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	28.00	84.00									28.00		56.00								28.00			
S4802	008	0		29	10	S4802_008_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	008	0		29	10	S4802_008_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	008	0		29	10	S4802_008_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	009	0		29	10	S4802_009_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
S4802	009	0		29	10	S4802_009_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	009	0		29	10	S4802_009_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	010	0		29	10	S4802_010_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	32.00	96.00									32.00		64.00								32.00			
S4802	010	0		29	10	S4802_010_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	010	0		29	10	S4802_010_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	011	0		29	10	S4802_011_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	011	0		29	10	S4802_011_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	29.00	87.00									29.00		58.00								29.00			
S4802	011	0		29	10	S4802_011_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	012	0		29	10	S4802_012_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	8.00	24.00									8.00		16.00								8.00			
S4802	012	0		29	10	S4802_012_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	29.00	87.00									29.00		58.00								29.00			
S4802	012	0		29	10	S4802_012_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	013	0		29	10	S4802_013_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	013	0		29	10	S4802_013_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	29.00	87.00									29.00		58.00								29.00			
S4802	013	0		29	10	S4802_013_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	014	0		29	10	S4802_014_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	014	0		29	10	S4802_014_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	28.00	84.00									28.00		56.00								28.00			
S4802	014	0		29	10	S4802_014_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	015	0		29	10	S4802_015_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	28.00	84.00									28.00		56.00								28.00			
S4802	015	0		29	10	S4802_015_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	015	0		29	10	S4802_015_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	016	0		29	10	S4802_016_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	016	0		29	10	S4802_016_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	016	0		29	10	S4802_016_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	017	0		29	10	S4802_017_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	33.00	99.00									33.00		66.00								33.00			
S4802	017	0		29	10	S4802_017_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	017	0		29	10	S4802_017_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	018	0		29	10	S4802_018_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
S4802	018	0		29	10	S4802_018_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	018	0		29	10	S4802_018_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	019	0		29	10	S4802_019_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	019	0		29	10	S4802_019_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.50	91.50									30.50		61.00								30.50			
S4802	019	0		29	10	S4802_019_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	020	0		29	10	S4802_020_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	020	0		29	10	S4802_020_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	020	0		29	10	S4802_020_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	021	0		29	10	S4802_021_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	021	0		29	10	S4802_021_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	32.00	96.00									32.00		64.00								32.00			
S4802	021	0		29	10	S4802_021_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	022	0		29	10	S4802_022_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	022	0		29	10	S4802_022_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	022	0		29	10	S4802_022_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	34.00	102.00									34.00		68.00								34.00			
S4802	023	0		29	10	S4802_023_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	023	0		29	10	S4802_023_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	023	0		29	10	S4802_023_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	024	0		29	10	S4802_024_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	024	0		29	10	S4802_024_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	024	0		29	10	S4802_024_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	025	0		29	10	S4802_025_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	30.00	90.00									30.00		60.00								30.00			
S4802	025	0		29	10	S4802_025_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	025	0		29	10	S4802_025_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	026	0		29	10	S4802_026_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	28.00	84.00									28.00		56.00								28.00			
S4802	026	0		29	10	S4802_026_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	026	0		29	10	S4802_026_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	027	0		29	10	S4802_027_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	027	0		29	10	S4802_027_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	32.00	96.00									32.00		64.00								32.00			
S4802	027	0		29	10	S4802_027_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	028	0		29	10	S4802_028_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	35.00	105.00									35.00		70.00								35.00			
S4802	028	0		29	10	S4802_028_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	028	0		29	10	S4802_028_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	029	0		29	10	S4802_029_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	029	0		29	10	S4802_029_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	27.00	81.00									27.00		54.00								27.00			
S4802	029	0		29	10	S4802_029_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	030	0		29	10	S4802_030_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	030	0		29	10	S4802_030_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	31.00	93.00									31.00		62.00								31.00			
S4802	030	0		29	10	S4802_030_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	032	0		29	10	S4802_032_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	10.00	30.00									10.00		20.00								10.00			
S4802	032	0		29	10	S4802_032_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	32.00	96.00									32.00		64.00								32.00			
S4802	032	0		29	10	S4802_032_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	033	0		29	10	S4802_033_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S4802	033	0		29	10	S4802_033_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	033	0		29	10	S4802_033_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	31.00	93.00									31.00		62.00								31.00			
S4802	067	0		29	10	S4802_067_0	4	1	3	1	Generic	010000		2	2	Generic	111000000001010000000	30	90									10		90								31	1	Generic	2	Generic																						Generic	9.00	27.00									9.00		18.00								9.00			
S4802	067	0		29	10	S4802_067_0	4	2	3	1	Brand	000010		2	1	Brand	111000000001010000000	30	90									10		90								31	1	Brand	2	Brand																						Brand	32.00	96.00									32.00		64.00								32.00			
S4802	067	0		29	10	S4802_067_0	4	3	3	1	Specialty	000010		1	2	Specialty	111000000001010000000	30	90									10		90								31	1	Specialty	1	Specialty	25	25									25		25								25	Specialty																								
S5540	002	0		29	10	S5540_002_0	4	3	3	1	Tier 3 - Non-preferred brand	100000		2	1	Tier 3 - Non-preferred brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 3 - Non-preferred brand	2	Tier 3 - Non-preferred brand																						Tier 3 - Non-preferred brand	81.00	243.00	162.00							81.00					81.00	202.50	162.00	81.00	243.00	162.00	81.00			
S5540	002	0		29	10	S5540_002_0	4	2	3	1	Tier 2 - Preferred brand	000001		2	2	Tier 2 - Preferred brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 2 - Preferred brand	2	Tier 2 - Preferred brand																						Tier 2 - Preferred brand	41.00	123.00	82.00							41.00					41.00	102.50	82.00	41.00	123.00	82.00	41.00			
S5540	002	0		29	10	S5540_002_0	4	1	3	1	Tier 1 - Generics	010000		2	2	Tier 1 - Generics	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generics	2	Tier 1 - Generics																						Tier 1 - Generics	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00			
S5540	002	0		29	10	S5540_002_0	4	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 4 - Specialty	1	Tier 4 - Specialty	33	33	33							33					33	33	33	33	33	33	33	Tier 4 - Specialty																								
S5540	004	0		29	10	S5540_004_0	4	1	4	3	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00	1	1	
S5540	004	0		29	10	S5540_004_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																						2		
S5540	004	0		29	10	S5540_004_0	4	3	4	3	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred																								Tier 3 - Non-preferred		Tier 3 - Non-preferred																						Tier 3 - Non-preferred																						2		
S5540	004	0		29	10	S5540_004_0	4	4	4	1	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 4 - Specialty	1	Tier 4 - Specialty	33	33	33							33					33	33	33	33	33	33	33	Tier 4 - Specialty																								
S5540	004	0		29	10	S5540_004_0	4	3	4	1	Tier 3 - Non-preferred	100000	1	2	1	Tier 3 - Non-preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 3 - Non-preferred	2	Tier 3 - Non-preferred																						Tier 3 - Non-preferred	75.00	225.00	150.00							75.00					75.00	187.50	150.00	75.00	225.00	150.00	75.00			
S5540	004	0		29	10	S5540_004_0	4	4	4	3	Tier 4 - Specialty	010010	1	1	2	Tier 4 - Specialty																								Tier 4 - Specialty		Tier 4 - Specialty																						Tier 4 - Specialty																						2		
S5540	004	0		29	10	S5540_004_0	4	1	4	1	Tier 1 - Generic	010000	1	2	2	Tier 1 - Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	6.00	18.00	12.00							6.00					0.00	0.00	0.00	6.00	18.00	12.00	6.00			
S5540	004	0		29	10	S5540_004_0	4	2	4	1	Tier 2 - Preferred Brand	000001	1	2	2	Tier 2 - Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	35.00	105.00	70.00							35.00					35.00	87.50	70.00	35.00	105.00	70.00	35.00			
S5552	001	0		29	10	S5552_001_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				41	41		46	46		41					41	41		41	41		41	Non-Preferred Brand																								
S5552	001	0		29	10	S5552_001_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5552	001	0		29	10	S5552_001_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5552	002	0		29	10	S5552_002_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5552	002	0		29	10	S5552_002_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5552	002	0		29	10	S5552_002_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5552	002	0		29	10	S5552_002_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5552	002	0		29	10	S5552_002_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5552	002	0		29	10	S5552_002_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5552	002	0		29	10	S5552_002_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5552	002	0		29	10	S5552_002_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5552	003	0		29	10	S5552_003_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5552	003	0		29	10	S5552_003_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5552	003	0		29	10	S5552_003_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				38	38		43	43		38					38	38		38	38		38	Non-Preferred Brand																								
S5555	001	0		29	10	S5555_001_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	10.00								5.00			
S5555	001	0		29	10	S5555_001_0	1	4	4	1	Specialty	110001	1	1	2	Specialty	111000000010110000000	30	90								30		30	90								31	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
S5555	001	0		29	10	S5555_001_0	1	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	50.00	150.00								50.00		50.00	100.00								50.00			
S5555	001	0		29	10	S5555_001_0	1	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	60.00								30.00			
S5557	004	0		29	10	S5557_004_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	004	0		29	10	S5557_004_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	004	0		29	10	S5557_004_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	004	0		29	10	S5557_004_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	004	0		29	10	S5557_004_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	006	0		29	10	S5557_006_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	006	0		29	10	S5557_006_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	006	0		29	10	S5557_006_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				35	35		45	45		45		35	25								45	Tier 3																								
S5557	006	0		29	10	S5557_006_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	006	0		29	10	S5557_006_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	009	0		29	10	S5557_009_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	009	0		29	10	S5557_009_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	009	0		29	10	S5557_009_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	009	0		29	10	S5557_009_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	009	0		29	10	S5557_009_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	009	0		29	10	S5557_009_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	009	0		29	10	S5557_009_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	009	0		29	10	S5557_009_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				45.00	135.00		60.00	180.00		60.00		45.00	90.00								60.00			
S5557	009	0		29	10	S5557_009_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				41.00	123.00		56.00	168.00		56.00		41.00	82.00								56.00			
S5557	009	0		29	10	S5557_009_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	011	0		29	10	S5557_011_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	011	0		29	10	S5557_011_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	011	0		29	10	S5557_011_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	011	0		29	10	S5557_011_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	011	0		29	10	S5557_011_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	011	0		29	10	S5557_011_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	011	0		29	10	S5557_011_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				41.00	123.00		56.00	168.00		56.00		41.00	82.00								56.00			
S5557	011	0		29	10	S5557_011_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				37.00	111.00		52.00	156.00		52.00		37.00	74.00								52.00			
S5557	011	0		29	10	S5557_011_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	011	0		29	10	S5557_011_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	013	0		29	10	S5557_013_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	013	0		29	10	S5557_013_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	013	0		29	10	S5557_013_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	013	0		29	10	S5557_013_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	013	0		29	10	S5557_013_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	013	0		29	10	S5557_013_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	013	0		29	10	S5557_013_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				41.00	123.00		56.00	168.00		56.00		41.00	82.00								56.00			
S5557	013	0		29	10	S5557_013_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				37.00	111.00		52.00	156.00		52.00		37.00	74.00								52.00			
S5557	013	0		29	10	S5557_013_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	013	0		29	10	S5557_013_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	015	0		29	10	S5557_015_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	015	0		29	10	S5557_015_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	015	0		29	10	S5557_015_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				34.00	102.00		49.00	147.00		49.00		34.00	68.00								49.00			
S5557	015	0		29	10	S5557_015_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				30.00	90.00		45.00	135.00		45.00		30.00	60.00								45.00			
S5557	015	0		29	10	S5557_015_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	015	0		29	10	S5557_015_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	015	0		29	10	S5557_015_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	015	0		29	10	S5557_015_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	015	0		29	10	S5557_015_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	015	0		29	10	S5557_015_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	017	0		29	10	S5557_017_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	017	0		29	10	S5557_017_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				37.00	111.00		52.00	156.00		52.00		37.00	74.00								52.00			
S5557	017	0		29	10	S5557_017_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				41.00	123.00		56.00	168.00		56.00		41.00	82.00								56.00			
S5557	017	0		29	10	S5557_017_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	017	0		29	10	S5557_017_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	017	0		29	10	S5557_017_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	017	0		29	10	S5557_017_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	017	0		29	10	S5557_017_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	017	0		29	10	S5557_017_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	017	0		29	10	S5557_017_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	019	0		29	10	S5557_019_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	019	0		29	10	S5557_019_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	019	0		29	10	S5557_019_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	019	0		29	10	S5557_019_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	019	0		29	10	S5557_019_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	019	0		29	10	S5557_019_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	019	0		29	10	S5557_019_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	019	0		29	10	S5557_019_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				36.00	108.00		51.00	153.00		51.00		36.00	72.00								51.00			
S5557	019	0		29	10	S5557_019_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				40.00	120.00		55.00	165.00		55.00		40.00	80.00								55.00			
S5557	019	0		29	10	S5557_019_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	021	0		29	10	S5557_021_0	2	2	4	3	Tier 2	000100	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5557	021	0		29	10	S5557_021_0	2	3	4	3	Tier 3	000001	1	2	2	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5557	021	0		29	10	S5557_021_0	2	4	4	3	Tier 4	100000	1	2	1	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5557	021	0		29	10	S5557_021_0	2	5	4	3	Tier 5	010010	1	1	2	Tier 5																								Tier 5		Tier 5																						Tier 5																						2		
S5557	021	0		29	10	S5557_021_0	2	1	4	1	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00			
S5557	021	0		29	10	S5557_021_0	2	2	4	1	Tier 2	000100	1	2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	2	Tier 2																						Tier 2				37.00	111.00		52.00	156.00		52.00		37.00	74.00								52.00			
S5557	021	0		29	10	S5557_021_0	2	3	4	1	Tier 3	000001	1	2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	2	Tier 3																						Tier 3				41.00	123.00		56.00	168.00		56.00		41.00	82.00								56.00			
S5557	021	0		29	10	S5557_021_0	2	4	4	1	Tier 4	100000	1	2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	2	Tier 4																						Tier 4				95.00	285.00		110.00	330.00		110.00		95.00	190.00								110.00			
S5557	021	0		29	10	S5557_021_0	2	5	4	1	Tier 5	010010	1	1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				33			33			33		33									33	Tier 5																								
S5557	021	0		29	10	S5557_021_0	2	1	4	3	Tier 1	001000	1	2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	2	Tier 1																						Tier 1				1.00	3.00		16.00	48.00		16.00		1.00	2.00								16.00	1	1	
S5557	023	0		29	10	S5557_023_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011111110110000000				30	90	60	30	90	60	30		30	90								31	1	Tier 2	1	Tier 2				50	50	50	60	60	60	60		50	50								60	Tier 2																								
S5557	023	0		29	10	S5557_023_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011111110110000000				30	90	60	30	90	60	30		30	90								31	1	Tier 3	1	Tier 3				33	33	33	43	43	43	43		33	23								43	Tier 3																								
S5557	023	0		29	10	S5557_023_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011111110110000000				30	90	60	30	90	60	30		30	90								31	1	Tier 4	1	Tier 4				60	60	60	70	70	70	70		60	50								70	Tier 4																								
S5557	023	0		29	10	S5557_023_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	023	0		29	10	S5557_023_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011111110110000000				30	90	60	30	90	60	30		30	90								31	1	Tier 1	1	Tier 1				0	0	0	20	20	20	20		0	0								20	Tier 1																								
S5557	024	0		29	10	S5557_024_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	024	0		29	10	S5557_024_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				38	38		48	48		48		38	28								48	Tier 3																								
S5557	024	0		29	10	S5557_024_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	024	0		29	10	S5557_024_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	024	0		29	10	S5557_024_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	025	0		29	10	S5557_025_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	025	0		29	10	S5557_025_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	025	0		29	10	S5557_025_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	025	0		29	10	S5557_025_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	025	0		29	10	S5557_025_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	028	0		29	10	S5557_028_0	3	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	028	0		29	10	S5557_028_0	3	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	028	0		29	10	S5557_028_0	3	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	028	0		29	10	S5557_028_0	3	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	028	0		29	10	S5557_028_0	3	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	031	0		29	10	S5557_031_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	031	0		29	10	S5557_031_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	031	0		29	10	S5557_031_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				39	39		49	49		49		39	29								49	Tier 3																								
S5557	031	0		29	10	S5557_031_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	031	0		29	10	S5557_031_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	034	0		29	10	S5557_034_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	034	0		29	10	S5557_034_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	034	0		29	10	S5557_034_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				35	35		45	45		45		35	25								45	Tier 3																								
S5557	034	0		29	10	S5557_034_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	034	0		29	10	S5557_034_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	036	0		29	10	S5557_036_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	036	0		29	10	S5557_036_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	036	0		29	10	S5557_036_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	036	0		29	10	S5557_036_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	036	0		29	10	S5557_036_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	038	0		29	10	S5557_038_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	038	0		29	10	S5557_038_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	038	0		29	10	S5557_038_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	038	0		29	10	S5557_038_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	038	0		29	10	S5557_038_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	040	0		29	10	S5557_040_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	040	0		29	10	S5557_040_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	040	0		29	10	S5557_040_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	040	0		29	10	S5557_040_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	040	0		29	10	S5557_040_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	042	0		29	10	S5557_042_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	042	0		29	10	S5557_042_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	042	0		29	10	S5557_042_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	042	0		29	10	S5557_042_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	042	0		29	10	S5557_042_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	044	0		29	10	S5557_044_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	044	0		29	10	S5557_044_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				35	35		45	45		45		35	25								45	Tier 3																								
S5557	044	0		29	10	S5557_044_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	044	0		29	10	S5557_044_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	044	0		29	10	S5557_044_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	046	0		29	10	S5557_046_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	046	0		29	10	S5557_046_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	046	0		29	10	S5557_046_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	046	0		29	10	S5557_046_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	046	0		29	10	S5557_046_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	048	0		29	10	S5557_048_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	048	0		29	10	S5557_048_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	048	0		29	10	S5557_048_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	048	0		29	10	S5557_048_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	048	0		29	10	S5557_048_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	050	0		29	10	S5557_050_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	050	0		29	10	S5557_050_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	050	0		29	10	S5557_050_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	050	0		29	10	S5557_050_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	050	0		29	10	S5557_050_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	052	0		29	10	S5557_052_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	052	0		29	10	S5557_052_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	052	0		29	10	S5557_052_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	052	0		29	10	S5557_052_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	052	0		29	10	S5557_052_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	054	0		29	10	S5557_054_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	054	0		29	10	S5557_054_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	054	0		29	10	S5557_054_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5557	054	0		29	10	S5557_054_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				40	40		50	50		50		40	30								50	Tier 3																								
S5557	054	0		29	10	S5557_054_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	056	0		29	10	S5557_056_0	2	1	2	1	Tier 1	001000		2	2	Tier 1	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 1	1	Tier 1				0	0		20	20		20		0	0								20	Tier 1																								
S5557	056	0		29	10	S5557_056_0	2	2	2	1	Tier 2	000100		2	2	Tier 2	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 2	1	Tier 2				50	50		60	60		60		50	50								60	Tier 2																								
S5557	056	0		29	10	S5557_056_0	2	3	2	1	Tier 3	000001		2	2	Tier 3	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 3	1	Tier 3				34	34		44	44		44		34	24								44	Tier 3																								
S5557	056	0		29	10	S5557_056_0	2	5	2	1	Tier 5	010010		1	2	Tier 5	100010010010100000000				30			30			30		30									31		Tier 5	1	Tier 5				25			25			25		25									25	Tier 5																								
S5557	056	0		29	10	S5557_056_0	2	4	2	1	Tier 4	100000		2	1	Tier 4	100011011010110000000				30	90		30	90		30		30	90								31	1	Tier 4	1	Tier 4				60	60		70	70		70		60	50								70	Tier 4																								
S5566	001	0		29	10	S5566_001_0	4	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				83.00	207.50		83.00	249.00		83.00			207.50								83.00			
S5566	001	0		29	10	S5566_001_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				33.00	82.50		33.00	99.00		33.00			82.50								33.00			
S5566	001	0		29	10	S5566_001_0	4	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				3.00	7.50		3.00	9.00		3.00			7.50								3.00			
S5566	001	0		29	10	S5566_001_0	4	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
S5566	002	0		29	10	S5566_002_0	5	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				89.00	222.50		89.00	267.00		89.00			222.50								89.00			
S5566	002	0		29	10	S5566_002_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	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	5	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				10.00	25.00		10.00	30.00		10.00			25.00								10.00			
S5566	002	0		29	10	S5566_002_0	5	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5566	003	0		29	10	S5566_003_0	3	3	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
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																						2		
S5566	003	0		29	10	S5566_003_0	3	1	4	3	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				6.00	15.00		6.00	18.00		6.00			15.00								6.00	1	1	
S5566	003	0		29	10	S5566_003_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5566	003	0		29	10	S5566_003_0	3	3	4	1	Brand	000010	1	2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				75.00	187.50		75.00	225.00		75.00			187.50								75.00			
S5566	003	0		29	10	S5566_003_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	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	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	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	3	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																						1	2	01000000
S5569	003	0		29	10	S5569_003_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5569	003	0		29	10	S5569_003_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5569	003	0		29	10	S5569_003_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5569	003	0		29	10	S5569_003_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5569	005	0		29	10	S5569_005_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5569	005	0		29	10	S5569_005_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5569	005	0		29	10	S5569_005_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	49	49								49			49								49	Non-Preferred Generic and Non-Preferred Brand																								
S5569	005	0		29	10	S5569_005_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5580	003	0		29	10	S5580_003_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5580	003	0		29	10	S5580_003_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	10.00	28.00								10.00			26.00								10.00			
S5580	003	0		29	10	S5580_003_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	98.00								39.00			78.00								39.00			
S5580	003	0		29	10	S5580_003_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	195.00								78.00			156.00								78.00			
S5580	004	0		29	10	S5580_004_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5580	004	0		29	10	S5580_004_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5580	004	0		29	10	S5580_004_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5580	004	0		29	10	S5580_004_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5584	001	0		29	10	S5584_001_0	2	4	3	1	Specialty	010010		1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
S5584	001	0		29	10	S5584_001_0	2	3	3	1	Non Preferred	100100		2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
S5584	001	0		29	10	S5584_001_0	2	1	3	1	Generic	001000		2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	2	5	3	1	Non Self Administered Injectable	010010		2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
S5584	002	0		29	10	S5584_002_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5584	002	0		29	10	S5584_002_0	3	1	4	3	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	2	Generic																						Generic				7.00	17.50		7.00	21.00		7.00					7.00	17.50		7.00	21.00		7.00	1	1	
S5584	002	0		29	10	S5584_002_0	3	5	4	1	Non Self Administered Injectable	010010	1	2	2	Non Self Administered Injectable	100010010010000000000				31			31			31											31		Non Self Administered Injectable	1	Non Self Administered Injectable				25			25			25											25	Non Self Administered Injectable																								
S5584	002	0		29	10	S5584_002_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				31			31			31					31			31			31		Specialty	1	Specialty				25			25			25					25			25			25	Specialty																								
S5584	002	0		29	10	S5584_002_0	3	3	4	1	Non Preferred	100100	1	2	1	Non Preferred	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Non Preferred	2	Non Preferred																						Non Preferred				70.00	175.00		70.00	210.00		70.00					70.00	175.00		70.00	210.00		70.00			
S5584	002	0		29	10	S5584_002_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Preferred Brand	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	3	1	4	1	Generic	001000	3	2	2	Generic	100011011010000110110				31	90		31	90		31					31	90		31	90		31	1	Generic	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	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5584	002	0		29	10	S5584_002_0	3	3	4	3	Non Preferred	100100	1	2	1	Non Preferred																								Non Preferred		Non Preferred																						Non Preferred																						2		
S5584	002	0		29	10	S5584_002_0	3	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																						2		
S5585	001	0		29	10	S5585_001_0	6	1	3	1	Formulary Generics	001000		2	2	Formulary Generics	111000000010110000000	30	90								30		30	90								31	2	Formulary Generics	2	Formulary Generics																						Formulary Generics	6.00	18.00								6.00		6.00	15.00								6.00			
S5585	001	0		29	10	S5585_001_0	6	2	3	1	Formulary Brands	000001		2	2	Formulary Brands	111000000010110000000	30	90								30		30	90								31	2	Formulary Brands	2	Formulary Brands																						Formulary Brands	40.00	120.00								40.00		40.00	100.00								40.00			
S5585	001	0		29	10	S5585_001_0	6	3	3	1	Non Preferred Generic/Brand	100100		2	1	Non Preferred Generic/Brand	111000000010110000000	30	90								30		30	90								31	2	Non Preferred Generic/Brand	1	Non Preferred Generic/Brand	40	40								40		40	33								40	Non Preferred Generic/Brand																								
S5585	001	0		29	10	S5585_001_0	6	4	3	1	Specialty Injectables	100000		1	2	Specialty Injectables	111000000010110000000	30	90								30		30	90								31	2	Specialty Injectables	1	Specialty Injectables	25	25								25		25	21								25	Specialty Injectables																								
S5593	002	0		29	10	S5593_002_0	5	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00		225.00	225.00								90.00			
S5593	002	0		29	10	S5593_002_0	5	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00		100.00	100.00								40.00			
S5593	002	0		29	10	S5593_002_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
S5593	002	0		29	10	S5593_002_0	5	4	4	1	Specialty Tier	110001	1	1	2	Specialty Tier	111000000010110000000	34	90								34		34	90								34	2	Specialty Tier	1	Specialty Tier	33	33								33		33	33								33	Specialty Tier																								
S5593	003	0		29	10	S5593_003_0	6	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00	1	1	
S5593	003	0		29	10	S5593_003_0	6	2	4	3	Preferred Brand	000001	1	2	1	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5593	003	0		29	10	S5593_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																						2		
S5593	003	0		29	10	S5593_003_0	6	4	4	1	Specialty Tier	110001	1	1	2	Specialty Tier	111000000010110000000	34	90								34		34	90								34	2	Specialty Tier	1	Specialty Tier	33	33								33		33	33								33	Specialty Tier																								
S5593	003	0		29	10	S5593_003_0	6	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		175.00	175.00								70.00			
S5593	003	0		29	10	S5593_003_0	6	4	4	3	Specialty Tier	110001	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5593	003	0		29	10	S5593_003_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	7.00	21.00								7.00		17.50	17.50								7.00			
S5593	003	0		29	10	S5593_003_0	6	2	4	1	Preferred Brand	000001	1	2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00		87.50	87.50								35.00			
S5593	004	0		29	10	S5593_004_0	5	4	2	1	Specialty Tier	110001		1	2	Specialty Tier	111000000010110000000	34	90								34		34	90								34	2	Specialty Tier	1	Specialty Tier	25	25								25		25	25								25	Specialty Tier																								
S5593	004	0		29	10	S5593_004_0	5	3	2	1	Non Preferred Brand	100000		2	2	Non Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Non Preferred Brand	2	Non Preferred Brand																						Non Preferred Brand	63.00	189.00								63.00		157.50	157.50								63.00			
S5593	004	0		29	10	S5593_004_0	5	2	2	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	33.00	99.00								33.00		82.50	82.50								33.00			
S5593	004	0		29	10	S5593_004_0	5	1	2	1	Generic	010000		2	2	Generic	111000000010110000000	34	90								34		34	90								34	2	Generic	2	Generic																						Generic	4.00	12.00								4.00		10.00	10.00								4.00			
S5596	001	0		29	10	S5596_001_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	001	0		29	10	S5596_001_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	001	0		29	10	S5596_001_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	001	0		29	10	S5596_001_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	001	0		29	10	S5596_001_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	003	0		29	10	S5596_003_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	003	0		29	10	S5596_003_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	003	0		29	10	S5596_003_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	003	0		29	10	S5596_003_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	003	0		29	10	S5596_003_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	003	0		29	10	S5596_003_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	003	0		29	10	S5596_003_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	003	0		29	10	S5596_003_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	003	0		29	10	S5596_003_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	003	0		29	10	S5596_003_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	005	0		29	10	S5596_005_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	005	0		29	10	S5596_005_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	005	0		29	10	S5596_005_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	005	0		29	10	S5596_005_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5596	006	0		29	10	S5596_006_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	006	0		29	10	S5596_006_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	006	0		29	10	S5596_006_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	006	0		29	10	S5596_006_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	006	0		29	10	S5596_006_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	007	0		29	10	S5596_007_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	007	0		29	10	S5596_007_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	007	0		29	10	S5596_007_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	007	0		29	10	S5596_007_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	007	0		29	10	S5596_007_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	007	0		29	10	S5596_007_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	007	0		29	10	S5596_007_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	007	0		29	10	S5596_007_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	007	0		29	10	S5596_007_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	007	0		29	10	S5596_007_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	009	0		29	10	S5596_009_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	5.50	16.50								5.50						8.25			16.50		5.50			
S5596	009	0		29	10	S5596_009_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	009	0		29	10	S5596_009_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	009	0		29	10	S5596_009_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	010	0		29	10	S5596_010_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	010	0		29	10	S5596_010_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	010	0		29	10	S5596_010_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	010	0		29	10	S5596_010_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	010	0		29	10	S5596_010_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	011	0		29	10	S5596_011_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	011	0		29	10	S5596_011_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	011	0		29	10	S5596_011_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	011	0		29	10	S5596_011_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	011	0		29	10	S5596_011_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	011	0		29	10	S5596_011_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	011	0		29	10	S5596_011_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	011	0		29	10	S5596_011_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	011	0		29	10	S5596_011_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	011	0		29	10	S5596_011_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	013	0		29	10	S5596_013_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	013	0		29	10	S5596_013_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	013	0		29	10	S5596_013_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	013	0		29	10	S5596_013_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5596	014	0		29	10	S5596_014_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	014	0		29	10	S5596_014_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	014	0		29	10	S5596_014_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	014	0		29	10	S5596_014_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	014	0		29	10	S5596_014_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	015	0		29	10	S5596_015_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	015	0		29	10	S5596_015_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	015	0		29	10	S5596_015_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	015	0		29	10	S5596_015_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	015	0		29	10	S5596_015_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	015	0		29	10	S5596_015_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	015	0		29	10	S5596_015_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	015	0		29	10	S5596_015_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	015	0		29	10	S5596_015_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	015	0		29	10	S5596_015_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	017	0		29	10	S5596_017_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5596	017	0		29	10	S5596_017_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	017	0		29	10	S5596_017_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	017	0		29	10	S5596_017_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	018	0		29	10	S5596_018_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	018	0		29	10	S5596_018_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	018	0		29	10	S5596_018_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	018	0		29	10	S5596_018_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	018	0		29	10	S5596_018_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	019	0		29	10	S5596_019_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	019	0		29	10	S5596_019_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	019	0		29	10	S5596_019_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	019	0		29	10	S5596_019_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	019	0		29	10	S5596_019_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	019	0		29	10	S5596_019_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	019	0		29	10	S5596_019_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	019	0		29	10	S5596_019_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	019	0		29	10	S5596_019_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	019	0		29	10	S5596_019_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	021	0		29	10	S5596_021_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	021	0		29	10	S5596_021_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	021	0		29	10	S5596_021_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5596	021	0		29	10	S5596_021_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	022	0		29	10	S5596_022_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	022	0		29	10	S5596_022_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	022	0		29	10	S5596_022_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	022	0		29	10	S5596_022_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	022	0		29	10	S5596_022_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	023	0		29	10	S5596_023_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	023	0		29	10	S5596_023_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	023	0		29	10	S5596_023_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	023	0		29	10	S5596_023_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	023	0		29	10	S5596_023_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	023	0		29	10	S5596_023_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	023	0		29	10	S5596_023_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	023	0		29	10	S5596_023_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	023	0		29	10	S5596_023_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	023	0		29	10	S5596_023_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	025	0		29	10	S5596_025_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	025	0		29	10	S5596_025_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	025	0		29	10	S5596_025_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5596	025	0		29	10	S5596_025_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	026	0		29	10	S5596_026_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	026	0		29	10	S5596_026_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	026	0		29	10	S5596_026_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	026	0		29	10	S5596_026_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	026	0		29	10	S5596_026_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	027	0		29	10	S5596_027_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	027	0		29	10	S5596_027_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	027	0		29	10	S5596_027_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	027	0		29	10	S5596_027_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	027	0		29	10	S5596_027_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	027	0		29	10	S5596_027_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	027	0		29	10	S5596_027_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	027	0		29	10	S5596_027_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	027	0		29	10	S5596_027_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	027	0		29	10	S5596_027_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	029	0		29	10	S5596_029_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	029	0		29	10	S5596_029_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	029	0		29	10	S5596_029_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	029	0		29	10	S5596_029_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	030	0		29	10	S5596_030_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	030	0		29	10	S5596_030_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	030	0		29	10	S5596_030_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	030	0		29	10	S5596_030_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	030	0		29	10	S5596_030_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	031	0		29	10	S5596_031_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	031	0		29	10	S5596_031_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	031	0		29	10	S5596_031_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	031	0		29	10	S5596_031_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	031	0		29	10	S5596_031_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	031	0		29	10	S5596_031_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	031	0		29	10	S5596_031_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	031	0		29	10	S5596_031_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	031	0		29	10	S5596_031_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	031	0		29	10	S5596_031_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	033	0		29	10	S5596_033_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	033	0		29	10	S5596_033_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	033	0		29	10	S5596_033_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5596	033	0		29	10	S5596_033_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5596	034	0		29	10	S5596_034_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	034	0		29	10	S5596_034_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	034	0		29	10	S5596_034_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	034	0		29	10	S5596_034_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	034	0		29	10	S5596_034_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	035	0		29	10	S5596_035_0	5	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	035	0		29	10	S5596_035_0	5	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	035	0		29	10	S5596_035_0	5	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	035	0		29	10	S5596_035_0	5	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	035	0		29	10	S5596_035_0	5	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	035	0		29	10	S5596_035_0	5	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	035	0		29	10	S5596_035_0	5	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	035	0		29	10	S5596_035_0	5	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	035	0		29	10	S5596_035_0	5	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	035	0		29	10	S5596_035_0	5	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	043	0		29	10	S5596_043_0	6	1	3	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.80	23.40								7.80						11.70			23.40		7.80			
S5596	043	0		29	10	S5596_043_0	6	2	3	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	45.00	135.00								45.00						112.50			135.00		45.00			
S5596	043	0		29	10	S5596_043_0	6	3	3	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	29	29								29						29			29		29	Tier 3 Non-Specialty Injectable Drugs																								
S5596	043	0		29	10	S5596_043_0	6	4	3	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	29									29					29			29			29	Tier 4 Specialty Drugs																								
S5596	044	0		29	10	S5596_044_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	044	0		29	10	S5596_044_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	044	0		29	10	S5596_044_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	044	0		29	10	S5596_044_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	044	0		29	10	S5596_044_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	045	0		29	10	S5596_045_0	4	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5596	045	0		29	10	S5596_045_0	4	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5596	045	0		29	10	S5596_045_0	4	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5596	045	0		29	10	S5596_045_0	4	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5596	045	0		29	10	S5596_045_0	4	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5596	045	0		29	10	S5596_045_0	4	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5596	045	0		29	10	S5596_045_0	4	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5596	045	0		29	10	S5596_045_0	4	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5596	045	0		29	10	S5596_045_0	4	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5596	045	0		29	10	S5596_045_0	4	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5596	046	0		29	10	S5596_046_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5596	046	0		29	10	S5596_046_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5596	046	0		29	10	S5596_046_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.50	22.50								7.50						11.25			22.50		7.50			
S5596	046	0		29	10	S5596_046_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5597	034	0		29	10	S5597_034_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	034	0		29	10	S5597_034_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	034	0		29	10	S5597_034_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	035	0		29	10	S5597_035_0	3	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	035	0		29	10	S5597_035_0	3	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	035	0		29	10	S5597_035_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	036	0		29	10	S5597_036_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	036	0		29	10	S5597_036_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	036	0		29	10	S5597_036_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	037	0		29	10	S5597_037_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	037	0		29	10	S5597_037_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	037	0		29	10	S5597_037_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	038	0		29	10	S5597_038_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	038	0		29	10	S5597_038_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	038	0		29	10	S5597_038_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	039	0		29	10	S5597_039_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	039	0		29	10	S5597_039_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	039	0		29	10	S5597_039_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	040	0		29	10	S5597_040_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	040	0		29	10	S5597_040_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	040	0		29	10	S5597_040_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	041	0		29	10	S5597_041_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	041	0		29	10	S5597_041_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	041	0		29	10	S5597_041_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	042	0		29	10	S5597_042_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	042	0		29	10	S5597_042_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	042	0		29	10	S5597_042_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	043	0		29	10	S5597_043_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	043	0		29	10	S5597_043_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	043	0		29	10	S5597_043_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	044	0		29	10	S5597_044_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	044	0		29	10	S5597_044_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	044	0		29	10	S5597_044_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	045	0		29	10	S5597_045_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	045	0		29	10	S5597_045_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	045	0		29	10	S5597_045_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	046	0		29	10	S5597_046_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	046	0		29	10	S5597_046_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	046	0		29	10	S5597_046_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	047	0		29	10	S5597_047_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	047	0		29	10	S5597_047_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	047	0		29	10	S5597_047_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	048	0		29	10	S5597_048_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	048	0		29	10	S5597_048_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	048	0		29	10	S5597_048_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	049	0		29	10	S5597_049_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	049	0		29	10	S5597_049_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	049	0		29	10	S5597_049_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	050	0		29	10	S5597_050_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	050	0		29	10	S5597_050_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	050	0		29	10	S5597_050_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	051	0		29	10	S5597_051_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	051	0		29	10	S5597_051_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	051	0		29	10	S5597_051_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	052	0		29	10	S5597_052_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	052	0		29	10	S5597_052_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	052	0		29	10	S5597_052_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	053	0		29	10	S5597_053_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	053	0		29	10	S5597_053_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	053	0		29	10	S5597_053_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	054	0		29	10	S5597_054_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	054	0		29	10	S5597_054_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	054	0		29	10	S5597_054_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	055	0		29	10	S5597_055_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	055	0		29	10	S5597_055_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	055	0		29	10	S5597_055_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	056	0		29	10	S5597_056_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	056	0		29	10	S5597_056_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	056	0		29	10	S5597_056_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	057	0		29	10	S5597_057_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	057	0		29	10	S5597_057_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	057	0		29	10	S5597_057_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	058	0		29	10	S5597_058_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	058	0		29	10	S5597_058_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	058	0		29	10	S5597_058_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	059	0		29	10	S5597_059_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	059	0		29	10	S5597_059_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	059	0		29	10	S5597_059_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	060	0		29	10	S5597_060_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	060	0		29	10	S5597_060_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	060	0		29	10	S5597_060_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	061	0		29	10	S5597_061_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	061	0		29	10	S5597_061_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	061	0		29	10	S5597_061_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	062	0		29	10	S5597_062_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	062	0		29	10	S5597_062_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	062	0		29	10	S5597_062_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	063	0		29	10	S5597_063_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5597	063	0		29	10	S5597_063_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	063	0		29	10	S5597_063_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	064	0		29	10	S5597_064_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5597	064	0		29	10	S5597_064_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5597	064	0		29	10	S5597_064_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5601	002	0		29	10	S5601_002_0	3	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	002	0		29	10	S5601_002_0	3	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	002	0		29	10	S5601_002_0	3	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	28.00	84.00	56.00							28.00					23.50	70.00	46.75	28.00	84.00	56.00	28.00			
S5601	002	0		29	10	S5601_002_0	3	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	003	0		29	10	S5601_003_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	003	0		29	10	S5601_003_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	003	0		29	10	S5601_003_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	003	0		29	10	S5601_003_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	003	0		29	10	S5601_003_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	003	0		29	10	S5601_003_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	004	0		29	10	S5601_004_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	004	0		29	10	S5601_004_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	004	0		29	10	S5601_004_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	004	0		29	10	S5601_004_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	26.50	79.50	53.00							26.50					22.25	66.25	44.25	26.50	79.50	53.00	26.50			
S5601	005	0		29	10	S5601_005_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	005	0		29	10	S5601_005_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	005	0		29	10	S5601_005_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	005	0		29	10	S5601_005_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	005	0		29	10	S5601_005_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	005	0		29	10	S5601_005_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	006	0		29	10	S5601_006_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	23.50	70.50	47.00							23.50					19.75	58.75	39.25	23.50	70.50	47.00	23.50			
S5601	006	0		29	10	S5601_006_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	006	0		29	10	S5601_006_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	006	0		29	10	S5601_006_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	007	0		29	10	S5601_007_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	007	0		29	10	S5601_007_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	007	0		29	10	S5601_007_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	007	0		29	10	S5601_007_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	007	0		29	10	S5601_007_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	007	0		29	10	S5601_007_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	008	0		29	10	S5601_008_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	22.50	67.50	45.00							22.50					18.75	56.25	37.50	22.50	67.50	45.00	22.50			
S5601	008	0		29	10	S5601_008_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	008	0		29	10	S5601_008_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	008	0		29	10	S5601_008_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	009	0		29	10	S5601_009_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	009	0		29	10	S5601_009_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	009	0		29	10	S5601_009_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	009	0		29	10	S5601_009_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	009	0		29	10	S5601_009_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	009	0		29	10	S5601_009_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	010	0		29	10	S5601_010_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	010	0		29	10	S5601_010_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	28.00	84.00	56.00							28.00					23.50	70.00	46.75	28.00	84.00	56.00	28.00			
S5601	010	0		29	10	S5601_010_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	010	0		29	10	S5601_010_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	011	0		29	10	S5601_011_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	011	0		29	10	S5601_011_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	011	0		29	10	S5601_011_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	011	0		29	10	S5601_011_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	011	0		29	10	S5601_011_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	011	0		29	10	S5601_011_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	012	0		29	10	S5601_012_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	21.00	63.00	42.00							21.00					17.50	52.50	35.00	21.00	63.00	42.00	21.00			
S5601	012	0		29	10	S5601_012_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	012	0		29	10	S5601_012_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	012	0		29	10	S5601_012_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	013	0		29	10	S5601_013_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	013	0		29	10	S5601_013_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	013	0		29	10	S5601_013_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	013	0		29	10	S5601_013_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	013	0		29	10	S5601_013_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	013	0		29	10	S5601_013_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	014	0		29	10	S5601_014_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	22.00	66.00	44.00							22.00					18.50	55.00	36.75	22.00	66.00	44.00	22.00			
S5601	014	0		29	10	S5601_014_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	014	0		29	10	S5601_014_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	014	0		29	10	S5601_014_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	015	0		29	10	S5601_015_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	015	0		29	10	S5601_015_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	015	0		29	10	S5601_015_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	015	0		29	10	S5601_015_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	015	0		29	10	S5601_015_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	015	0		29	10	S5601_015_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	016	0		29	10	S5601_016_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	016	0		29	10	S5601_016_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	016	0		29	10	S5601_016_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	016	0		29	10	S5601_016_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	20.00	60.00	40.00							20.00					16.75	50.00	33.50	20.00	60.00	40.00	20.00			
S5601	017	0		29	10	S5601_017_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	017	0		29	10	S5601_017_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	017	0		29	10	S5601_017_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	017	0		29	10	S5601_017_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	017	0		29	10	S5601_017_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	017	0		29	10	S5601_017_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	018	0		29	10	S5601_018_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	018	0		29	10	S5601_018_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	018	0		29	10	S5601_018_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	018	0		29	10	S5601_018_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	21.25	63.75	42.50							21.25					17.75	53.25	35.50	21.25	63.75	42.50	21.25			
S5601	019	0		29	10	S5601_019_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	019	0		29	10	S5601_019_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	019	0		29	10	S5601_019_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	019	0		29	10	S5601_019_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	019	0		29	10	S5601_019_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	019	0		29	10	S5601_019_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	020	0		29	10	S5601_020_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	020	0		29	10	S5601_020_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	020	0		29	10	S5601_020_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	020	0		29	10	S5601_020_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	20.50	61.50	41.00							20.50					17.25	51.25	34.25	20.50	61.50	41.00	20.50			
S5601	021	0		29	10	S5601_021_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	021	0		29	10	S5601_021_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	021	0		29	10	S5601_021_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	021	0		29	10	S5601_021_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	021	0		29	10	S5601_021_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	021	0		29	10	S5601_021_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	022	0		29	10	S5601_022_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	022	0		29	10	S5601_022_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	25.50	76.50	51.00							25.50					21.25	63.75	42.50	25.50	76.50	51.00	25.50			
S5601	022	0		29	10	S5601_022_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	022	0		29	10	S5601_022_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	023	0		29	10	S5601_023_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	023	0		29	10	S5601_023_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	023	0		29	10	S5601_023_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	023	0		29	10	S5601_023_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	023	0		29	10	S5601_023_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	023	0		29	10	S5601_023_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	024	0		29	10	S5601_024_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	024	0		29	10	S5601_024_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	024	0		29	10	S5601_024_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	19.75	59.25	39.50							19.75					16.50	49.50	33.00	19.75	59.25	39.50	19.75			
S5601	024	0		29	10	S5601_024_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	025	0		29	10	S5601_025_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	025	0		29	10	S5601_025_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	025	0		29	10	S5601_025_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	025	0		29	10	S5601_025_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	025	0		29	10	S5601_025_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	025	0		29	10	S5601_025_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	026	0		29	10	S5601_026_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	026	0		29	10	S5601_026_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	27.25	81.75	54.50							27.25					22.75	68.25	45.50	27.25	81.75	54.50	27.25			
S5601	026	0		29	10	S5601_026_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	026	0		29	10	S5601_026_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	027	0		29	10	S5601_027_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	027	0		29	10	S5601_027_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	027	0		29	10	S5601_027_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	027	0		29	10	S5601_027_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	027	0		29	10	S5601_027_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	027	0		29	10	S5601_027_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	028	0		29	10	S5601_028_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	028	0		29	10	S5601_028_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	23.50	70.50	47.00							23.50					19.75	58.75	39.25	23.50	70.50	47.00	23.50			
S5601	028	0		29	10	S5601_028_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	028	0		29	10	S5601_028_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	029	0		29	10	S5601_029_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	029	0		29	10	S5601_029_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	029	0		29	10	S5601_029_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	029	0		29	10	S5601_029_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	029	0		29	10	S5601_029_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	029	0		29	10	S5601_029_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	030	0		29	10	S5601_030_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	22.50	67.50	45.00							22.50					18.75	56.25	37.50	22.50	67.50	45.00	22.50			
S5601	030	0		29	10	S5601_030_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	030	0		29	10	S5601_030_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	030	0		29	10	S5601_030_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	031	0		29	10	S5601_031_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	031	0		29	10	S5601_031_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	031	0		29	10	S5601_031_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	031	0		29	10	S5601_031_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	031	0		29	10	S5601_031_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	031	0		29	10	S5601_031_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	032	0		29	10	S5601_032_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	21.25	63.75	42.50							21.25					17.75	53.25	35.50	21.25	63.75	42.50	21.25			
S5601	032	0		29	10	S5601_032_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	032	0		29	10	S5601_032_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	032	0		29	10	S5601_032_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	033	0		29	10	S5601_033_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	033	0		29	10	S5601_033_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	033	0		29	10	S5601_033_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	033	0		29	10	S5601_033_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	033	0		29	10	S5601_033_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	033	0		29	10	S5601_033_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	034	0		29	10	S5601_034_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	034	0		29	10	S5601_034_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	034	0		29	10	S5601_034_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	20.00	60.00	40.00							20.00					16.75	50.00	33.50	20.00	60.00	40.00	20.00			
S5601	034	0		29	10	S5601_034_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	035	0		29	10	S5601_035_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	035	0		29	10	S5601_035_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	035	0		29	10	S5601_035_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	035	0		29	10	S5601_035_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	035	0		29	10	S5601_035_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	035	0		29	10	S5601_035_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	036	0		29	10	S5601_036_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	036	0		29	10	S5601_036_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	20.00	60.00	40.00							20.00					16.75	50.00	33.50	20.00	60.00	40.00	20.00			
S5601	036	0		29	10	S5601_036_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	036	0		29	10	S5601_036_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	037	0		29	10	S5601_037_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	037	0		29	10	S5601_037_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	037	0		29	10	S5601_037_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	037	0		29	10	S5601_037_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	037	0		29	10	S5601_037_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	037	0		29	10	S5601_037_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	038	0		29	10	S5601_038_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	038	0		29	10	S5601_038_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	038	0		29	10	S5601_038_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	18.00	54.00	36.00							18.00					15.00	45.00	30.00	18.00	54.00	36.00	18.00			
S5601	038	0		29	10	S5601_038_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	039	0		29	10	S5601_039_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	039	0		29	10	S5601_039_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	039	0		29	10	S5601_039_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	039	0		29	10	S5601_039_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	039	0		29	10	S5601_039_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	039	0		29	10	S5601_039_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	040	0		29	10	S5601_040_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	17.75	53.25	35.50							17.75					15.00	44.50	29.75	17.75	53.25	35.50	17.75			
S5601	040	0		29	10	S5601_040_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	040	0		29	10	S5601_040_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	040	0		29	10	S5601_040_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	041	0		29	10	S5601_041_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	041	0		29	10	S5601_041_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	041	0		29	10	S5601_041_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	041	0		29	10	S5601_041_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	041	0		29	10	S5601_041_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	041	0		29	10	S5601_041_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	042	0		29	10	S5601_042_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	19.25	57.75	38.50							19.25					16.25	48.25	32.25	19.25	57.75	38.50	19.25			
S5601	042	0		29	10	S5601_042_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	042	0		29	10	S5601_042_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	042	0		29	10	S5601_042_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	043	0		29	10	S5601_043_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	043	0		29	10	S5601_043_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	043	0		29	10	S5601_043_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	043	0		29	10	S5601_043_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	043	0		29	10	S5601_043_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	043	0		29	10	S5601_043_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	044	0		29	10	S5601_044_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	044	0		29	10	S5601_044_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	044	0		29	10	S5601_044_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	044	0		29	10	S5601_044_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	22.50	67.50	45.00							22.50					18.75	56.25	37.50	22.50	67.50	45.00	22.50			
S5601	045	0		29	10	S5601_045_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	045	0		29	10	S5601_045_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	045	0		29	10	S5601_045_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	045	0		29	10	S5601_045_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	045	0		29	10	S5601_045_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	045	0		29	10	S5601_045_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	046	0		29	10	S5601_046_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	046	0		29	10	S5601_046_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	046	0		29	10	S5601_046_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	046	0		29	10	S5601_046_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	24.25	72.75	48.50							24.25					20.25	60.75	40.50	24.25	72.75	48.50	24.25			
S5601	047	0		29	10	S5601_047_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	047	0		29	10	S5601_047_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	047	0		29	10	S5601_047_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	047	0		29	10	S5601_047_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	047	0		29	10	S5601_047_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	047	0		29	10	S5601_047_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	048	0		29	10	S5601_048_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	048	0		29	10	S5601_048_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	048	0		29	10	S5601_048_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	048	0		29	10	S5601_048_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	21.50	64.50	43.00							21.50					18.00	53.75	36.00	21.50	64.50	43.00	21.50			
S5601	049	0		29	10	S5601_049_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	049	0		29	10	S5601_049_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	049	0		29	10	S5601_049_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	049	0		29	10	S5601_049_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	049	0		29	10	S5601_049_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	049	0		29	10	S5601_049_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	050	0		29	10	S5601_050_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	21.50	64.50	43.00							21.50					18.00	53.75	36.00	21.50	64.50	43.00	21.50			
S5601	050	0		29	10	S5601_050_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	050	0		29	10	S5601_050_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	050	0		29	10	S5601_050_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	051	0		29	10	S5601_051_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	051	0		29	10	S5601_051_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	051	0		29	10	S5601_051_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	051	0		29	10	S5601_051_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	051	0		29	10	S5601_051_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	051	0		29	10	S5601_051_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	052	0		29	10	S5601_052_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	052	0		29	10	S5601_052_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	052	0		29	10	S5601_052_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	052	0		29	10	S5601_052_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	21.00	63.00	42.00							21.00					17.50	52.50	35.00	21.00	63.00	42.00	21.00			
S5601	053	0		29	10	S5601_053_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	053	0		29	10	S5601_053_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	053	0		29	10	S5601_053_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	053	0		29	10	S5601_053_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	053	0		29	10	S5601_053_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	053	0		29	10	S5601_053_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	054	0		29	10	S5601_054_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	054	0		29	10	S5601_054_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	054	0		29	10	S5601_054_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	054	0		29	10	S5601_054_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	24.50	73.50	49.00							24.50					20.50	61.25	41.00	24.50	73.50	49.00	24.50			
S5601	055	0		29	10	S5601_055_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	055	0		29	10	S5601_055_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	055	0		29	10	S5601_055_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	055	0		29	10	S5601_055_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	055	0		29	10	S5601_055_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	055	0		29	10	S5601_055_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	056	0		29	10	S5601_056_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	056	0		29	10	S5601_056_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	19.50	58.50	39.00							19.50					16.25	48.75	32.50	19.50	58.50	39.00	19.50			
S5601	056	0		29	10	S5601_056_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	056	0		29	10	S5601_056_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	057	0		29	10	S5601_057_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	057	0		29	10	S5601_057_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	057	0		29	10	S5601_057_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	057	0		29	10	S5601_057_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	057	0		29	10	S5601_057_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	057	0		29	10	S5601_057_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	058	0		29	10	S5601_058_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	058	0		29	10	S5601_058_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	058	0		29	10	S5601_058_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	058	0		29	10	S5601_058_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	23.75	71.25	47.50							23.75					20.00	59.50	39.75	23.75	71.25	47.50	23.75			
S5601	059	0		29	10	S5601_059_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	059	0		29	10	S5601_059_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	059	0		29	10	S5601_059_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	059	0		29	10	S5601_059_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	059	0		29	10	S5601_059_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	059	0		29	10	S5601_059_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	060	0		29	10	S5601_060_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	060	0		29	10	S5601_060_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	060	0		29	10	S5601_060_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	060	0		29	10	S5601_060_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	22.25	66.75	44.50							22.25					18.75	55.75	37.25	22.25	66.75	44.50	22.25			
S5601	061	0		29	10	S5601_061_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	061	0		29	10	S5601_061_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	061	0		29	10	S5601_061_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	061	0		29	10	S5601_061_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	061	0		29	10	S5601_061_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	061	0		29	10	S5601_061_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	062	0		29	10	S5601_062_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	062	0		29	10	S5601_062_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	25.25	75.75	50.50							25.25					21.25	63.25	42.25	25.25	75.75	50.50	25.25			
S5601	062	0		29	10	S5601_062_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	062	0		29	10	S5601_062_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	063	0		29	10	S5601_063_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	063	0		29	10	S5601_063_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	063	0		29	10	S5601_063_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	063	0		29	10	S5601_063_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	063	0		29	10	S5601_063_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	063	0		29	10	S5601_063_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	064	0		29	10	S5601_064_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	8.00	24.00	16.00							8.00					4.75	14.00	9.50	8.00	24.00	16.00	8.00			
S5601	064	0		29	10	S5601_064_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	26.00	78.00	52.00							26.00					21.75	65.00	43.50	26.00	78.00	52.00	26.00			
S5601	064	0		29	10	S5601_064_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	064	0		29	10	S5601_064_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	065	0		29	10	S5601_065_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	065	0		29	10	S5601_065_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	065	0		29	10	S5601_065_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	065	0		29	10	S5601_065_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	065	0		29	10	S5601_065_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	065	0		29	10	S5601_065_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	066	0		29	10	S5601_066_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	066	0		29	10	S5601_066_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	066	0		29	10	S5601_066_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	19.00	57.00	38.00							19.00					16.00	47.50	31.75	19.00	57.00	38.00	19.00			
S5601	066	0		29	10	S5601_066_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	067	0		29	10	S5601_067_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	067	0		29	10	S5601_067_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	067	0		29	10	S5601_067_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	067	0		29	10	S5601_067_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	067	0		29	10	S5601_067_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	067	0		29	10	S5601_067_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	068	0		29	10	S5601_068_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	068	0		29	10	S5601_068_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	16.25	48.75	32.50							16.25					13.75	40.75	27.25	16.25	48.75	32.50	16.25			
S5601	068	0		29	10	S5601_068_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	068	0		29	10	S5601_068_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	95.00	285.00	190.00							95.00					87.25	261.25	174.25	95.00	285.00	190.00	95.00			
S5601	069	0		29	10	S5601_069_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	069	0		29	10	S5601_069_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	069	0		29	10	S5601_069_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	069	0		29	10	S5601_069_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	069	0		29	10	S5601_069_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	069	0		29	10	S5601_069_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	070	0		29	10	S5601_070_0	2	1	2	1	Generic Tier	010000		2	2	Generic Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier	7.00	21.00	14.00							7.00					4.25	12.25	8.25	7.00	21.00	14.00	7.00			
S5601	070	0		29	10	S5601_070_0	2	2	2	1	Preferred Brand Tier	000001		2	2	Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier	15.00	45.00	30.00							15.00					12.50	37.50	25.00	15.00	45.00	30.00	15.00			
S5601	070	0		29	10	S5601_070_0	2	3	2	1	Non-Preferred Brand Tier	100000		2	1	Non-Preferred Brand Tier	111100000010000111111	34	90	60							34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier	70.00	210.00	140.00							70.00					64.25	192.50	128.50	70.00	210.00	140.00	70.00			
S5601	070	0		29	10	S5601_070_0	2	4	2	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010000000000	34									34											34		Specialty Tier	1	Specialty Tier	25									25											25	Specialty Tier																								
S5601	071	0		29	10	S5601_071_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	071	0		29	10	S5601_071_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					4.75	14.00	9.50	7.50	22.50	15.00	7.50			
S5601	071	0		29	10	S5601_071_0	2	3	4	1	Value Brand Tier	000001	1	2	2	Value Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Brand Tier	2	Value Brand Tier																						Value Brand Tier				25.00	75.00	50.00	30.00	90.00	60.00	30.00					21.00	63.00	42.00	30.00	90.00	60.00	30.00			
S5601	071	0		29	10	S5601_071_0	2	4	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				30.00	90.00	60.00	30.00	90.00	60.00	30.00					25.00	75.00	50.00	30.00	90.00	60.00	30.00			
S5601	071	0		29	10	S5601_071_0	2	6	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				31			31			31											31	Specialty Tier																								
S5601	071	0		29	10	S5601_071_0	2	5	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				90.00	270.00	180.00	90.00	270.00	180.00	90.00					82.75	248.00	165.50	90.00	270.00	180.00	90.00			
S5601	072	0		29	10	S5601_072_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	072	0		29	10	S5601_072_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	072	0		29	10	S5601_072_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	072	0		29	10	S5601_072_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	072	0		29	10	S5601_072_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	072	0		29	10	S5601_072_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	072	0		29	10	S5601_072_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	072	0		29	10	S5601_072_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	072	0		29	10	S5601_072_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	073	0		29	10	S5601_073_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	073	0		29	10	S5601_073_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	073	0		29	10	S5601_073_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	073	0		29	10	S5601_073_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	073	0		29	10	S5601_073_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	073	0		29	10	S5601_073_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	073	0		29	10	S5601_073_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	073	0		29	10	S5601_073_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	073	0		29	10	S5601_073_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	074	0		29	10	S5601_074_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	074	0		29	10	S5601_074_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	074	0		29	10	S5601_074_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	074	0		29	10	S5601_074_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	074	0		29	10	S5601_074_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	074	0		29	10	S5601_074_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	074	0		29	10	S5601_074_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	074	0		29	10	S5601_074_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	074	0		29	10	S5601_074_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	075	0		29	10	S5601_075_0	3	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	075	0		29	10	S5601_075_0	3	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	075	0		29	10	S5601_075_0	3	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	075	0		29	10	S5601_075_0	3	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	075	0		29	10	S5601_075_0	3	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	075	0		29	10	S5601_075_0	3	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	075	0		29	10	S5601_075_0	3	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	075	0		29	10	S5601_075_0	3	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	3	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	075	0		29	10	S5601_075_0	3	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	076	0		29	10	S5601_076_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	076	0		29	10	S5601_076_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	076	0		29	10	S5601_076_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	076	0		29	10	S5601_076_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	076	0		29	10	S5601_076_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	076	0		29	10	S5601_076_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	076	0		29	10	S5601_076_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	076	0		29	10	S5601_076_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	076	0		29	10	S5601_076_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	077	0		29	10	S5601_077_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	077	0		29	10	S5601_077_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	077	0		29	10	S5601_077_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	077	0		29	10	S5601_077_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	077	0		29	10	S5601_077_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	077	0		29	10	S5601_077_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	077	0		29	10	S5601_077_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	077	0		29	10	S5601_077_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	077	0		29	10	S5601_077_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	078	0		29	10	S5601_078_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	078	0		29	10	S5601_078_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	078	0		29	10	S5601_078_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	078	0		29	10	S5601_078_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	078	0		29	10	S5601_078_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	078	0		29	10	S5601_078_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	078	0		29	10	S5601_078_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	078	0		29	10	S5601_078_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	078	0		29	10	S5601_078_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	079	0		29	10	S5601_079_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	079	0		29	10	S5601_079_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	079	0		29	10	S5601_079_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	079	0		29	10	S5601_079_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	079	0		29	10	S5601_079_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	079	0		29	10	S5601_079_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	079	0		29	10	S5601_079_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	079	0		29	10	S5601_079_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	079	0		29	10	S5601_079_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	080	0		29	10	S5601_080_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	080	0		29	10	S5601_080_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	080	0		29	10	S5601_080_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	080	0		29	10	S5601_080_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	080	0		29	10	S5601_080_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	080	0		29	10	S5601_080_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	080	0		29	10	S5601_080_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	080	0		29	10	S5601_080_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	080	0		29	10	S5601_080_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	080	0		29	10	S5601_080_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	081	0		29	10	S5601_081_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	081	0		29	10	S5601_081_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	081	0		29	10	S5601_081_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	081	0		29	10	S5601_081_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	081	0		29	10	S5601_081_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	081	0		29	10	S5601_081_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	081	0		29	10	S5601_081_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	081	0		29	10	S5601_081_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	081	0		29	10	S5601_081_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	082	0		29	10	S5601_082_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	082	0		29	10	S5601_082_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	082	0		29	10	S5601_082_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	082	0		29	10	S5601_082_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	082	0		29	10	S5601_082_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	082	0		29	10	S5601_082_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	082	0		29	10	S5601_082_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	082	0		29	10	S5601_082_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	083	0		29	10	S5601_083_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	083	0		29	10	S5601_083_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	083	0		29	10	S5601_083_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	083	0		29	10	S5601_083_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	083	0		29	10	S5601_083_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	083	0		29	10	S5601_083_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	083	0		29	10	S5601_083_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	083	0		29	10	S5601_083_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	083	0		29	10	S5601_083_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	084	0		29	10	S5601_084_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	084	0		29	10	S5601_084_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	084	0		29	10	S5601_084_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	084	0		29	10	S5601_084_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	084	0		29	10	S5601_084_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	084	0		29	10	S5601_084_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	084	0		29	10	S5601_084_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	084	0		29	10	S5601_084_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	084	0		29	10	S5601_084_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	085	0		29	10	S5601_085_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	085	0		29	10	S5601_085_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	085	0		29	10	S5601_085_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	085	0		29	10	S5601_085_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	085	0		29	10	S5601_085_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	085	0		29	10	S5601_085_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	085	0		29	10	S5601_085_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	085	0		29	10	S5601_085_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	085	0		29	10	S5601_085_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	086	0		29	10	S5601_086_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	086	0		29	10	S5601_086_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	086	0		29	10	S5601_086_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	086	0		29	10	S5601_086_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	086	0		29	10	S5601_086_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	086	0		29	10	S5601_086_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	086	0		29	10	S5601_086_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	086	0		29	10	S5601_086_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	086	0		29	10	S5601_086_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	087	0		29	10	S5601_087_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	087	0		29	10	S5601_087_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	087	0		29	10	S5601_087_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	087	0		29	10	S5601_087_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	087	0		29	10	S5601_087_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	087	0		29	10	S5601_087_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	087	0		29	10	S5601_087_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	087	0		29	10	S5601_087_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	087	0		29	10	S5601_087_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	087	0		29	10	S5601_087_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	088	0		29	10	S5601_088_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	088	0		29	10	S5601_088_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	088	0		29	10	S5601_088_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	088	0		29	10	S5601_088_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	088	0		29	10	S5601_088_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	088	0		29	10	S5601_088_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	088	0		29	10	S5601_088_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	088	0		29	10	S5601_088_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	088	0		29	10	S5601_088_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	088	0		29	10	S5601_088_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	089	0		29	10	S5601_089_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	089	0		29	10	S5601_089_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	089	0		29	10	S5601_089_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	089	0		29	10	S5601_089_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	089	0		29	10	S5601_089_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	089	0		29	10	S5601_089_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	089	0		29	10	S5601_089_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	089	0		29	10	S5601_089_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	090	0		29	10	S5601_090_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	090	0		29	10	S5601_090_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	090	0		29	10	S5601_090_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	090	0		29	10	S5601_090_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	090	0		29	10	S5601_090_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	090	0		29	10	S5601_090_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	090	0		29	10	S5601_090_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	090	0		29	10	S5601_090_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	090	0		29	10	S5601_090_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	091	0		29	10	S5601_091_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	091	0		29	10	S5601_091_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	091	0		29	10	S5601_091_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	091	0		29	10	S5601_091_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	091	0		29	10	S5601_091_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	091	0		29	10	S5601_091_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	091	0		29	10	S5601_091_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	091	0		29	10	S5601_091_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	091	0		29	10	S5601_091_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	092	0		29	10	S5601_092_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	092	0		29	10	S5601_092_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	092	0		29	10	S5601_092_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	092	0		29	10	S5601_092_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	092	0		29	10	S5601_092_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	092	0		29	10	S5601_092_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	092	0		29	10	S5601_092_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	092	0		29	10	S5601_092_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	092	0		29	10	S5601_092_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	092	0		29	10	S5601_092_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	093	0		29	10	S5601_093_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	093	0		29	10	S5601_093_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	093	0		29	10	S5601_093_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	093	0		29	10	S5601_093_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	093	0		29	10	S5601_093_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	093	0		29	10	S5601_093_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	093	0		29	10	S5601_093_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	093	0		29	10	S5601_093_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	093	0		29	10	S5601_093_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	093	0		29	10	S5601_093_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	094	0		29	10	S5601_094_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	094	0		29	10	S5601_094_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	094	0		29	10	S5601_094_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	094	0		29	10	S5601_094_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	094	0		29	10	S5601_094_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	094	0		29	10	S5601_094_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	094	0		29	10	S5601_094_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	094	0		29	10	S5601_094_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	095	0		29	10	S5601_095_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	095	0		29	10	S5601_095_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	095	0		29	10	S5601_095_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	095	0		29	10	S5601_095_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	095	0		29	10	S5601_095_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	095	0		29	10	S5601_095_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	095	0		29	10	S5601_095_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	095	0		29	10	S5601_095_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	095	0		29	10	S5601_095_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	096	0		29	10	S5601_096_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	096	0		29	10	S5601_096_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	096	0		29	10	S5601_096_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	096	0		29	10	S5601_096_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	096	0		29	10	S5601_096_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	096	0		29	10	S5601_096_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	096	0		29	10	S5601_096_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	096	0		29	10	S5601_096_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	096	0		29	10	S5601_096_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	097	0		29	10	S5601_097_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	097	0		29	10	S5601_097_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	097	0		29	10	S5601_097_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	097	0		29	10	S5601_097_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	097	0		29	10	S5601_097_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	097	0		29	10	S5601_097_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	097	0		29	10	S5601_097_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	097	0		29	10	S5601_097_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	097	0		29	10	S5601_097_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	098	0		29	10	S5601_098_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	098	0		29	10	S5601_098_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	098	0		29	10	S5601_098_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	098	0		29	10	S5601_098_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	098	0		29	10	S5601_098_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	098	0		29	10	S5601_098_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	098	0		29	10	S5601_098_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	098	0		29	10	S5601_098_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	098	0		29	10	S5601_098_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	099	0		29	10	S5601_099_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	099	0		29	10	S5601_099_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	099	0		29	10	S5601_099_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	099	0		29	10	S5601_099_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	099	0		29	10	S5601_099_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	099	0		29	10	S5601_099_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	099	0		29	10	S5601_099_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	099	0		29	10	S5601_099_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	099	0		29	10	S5601_099_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	100	0		29	10	S5601_100_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	100	0		29	10	S5601_100_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	100	0		29	10	S5601_100_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	100	0		29	10	S5601_100_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	100	0		29	10	S5601_100_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	100	0		29	10	S5601_100_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	100	0		29	10	S5601_100_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	100	0		29	10	S5601_100_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	100	0		29	10	S5601_100_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	101	0		29	10	S5601_101_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	101	0		29	10	S5601_101_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	101	0		29	10	S5601_101_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	101	0		29	10	S5601_101_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	101	0		29	10	S5601_101_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	101	0		29	10	S5601_101_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	101	0		29	10	S5601_101_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	101	0		29	10	S5601_101_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	101	0		29	10	S5601_101_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	102	0		29	10	S5601_102_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	102	0		29	10	S5601_102_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	102	0		29	10	S5601_102_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	102	0		29	10	S5601_102_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	102	0		29	10	S5601_102_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	102	0		29	10	S5601_102_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	102	0		29	10	S5601_102_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	102	0		29	10	S5601_102_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	102	0		29	10	S5601_102_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	103	0		29	10	S5601_103_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	103	0		29	10	S5601_103_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	103	0		29	10	S5601_103_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	103	0		29	10	S5601_103_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	103	0		29	10	S5601_103_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	103	0		29	10	S5601_103_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	103	0		29	10	S5601_103_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	103	0		29	10	S5601_103_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	103	0		29	10	S5601_103_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	104	0		29	10	S5601_104_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	104	0		29	10	S5601_104_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	104	0		29	10	S5601_104_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	104	0		29	10	S5601_104_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	104	0		29	10	S5601_104_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	104	0		29	10	S5601_104_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	104	0		29	10	S5601_104_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	104	0		29	10	S5601_104_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	104	0		29	10	S5601_104_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	105	0		29	10	S5601_105_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	105	0		29	10	S5601_105_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	105	0		29	10	S5601_105_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	105	0		29	10	S5601_105_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	105	0		29	10	S5601_105_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	105	0		29	10	S5601_105_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5601	105	0		29	10	S5601_105_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	105	0		29	10	S5601_105_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	105	0		29	10	S5601_105_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	106	0		29	10	S5601_106_0	2	1	4	1	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	7.50	22.50	15.00	7.50					1.75	5.00	3.50	7.50	22.50	15.00	7.50			
S5601	106	0		29	10	S5601_106_0	2	2	4	1	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	7.50	22.50	15.00	7.50					6.50	19.00	12.75	7.50	22.50	15.00	7.50			
S5601	106	0		29	10	S5601_106_0	2	3	4	1	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Preferred Brand Tier	2	Preferred Brand Tier																						Preferred Brand Tier				39.00	117.00	78.00	39.00	117.00	78.00	39.00					32.75	98.00	65.50	39.00	117.00	78.00	39.00			
S5601	106	0		29	10	S5601_106_0	2	4	4	1	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Non-Preferred Brand Tier	2	Non-Preferred Brand Tier																						Non-Preferred Brand Tier				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	106	0		29	10	S5601_106_0	2	5	4	3	Specialty Tier	010010	1	1	2	Specialty Tier																								Specialty Tier		Specialty Tier																						Specialty Tier																						2		
S5601	106	0		29	10	S5601_106_0	2	1	4	3	Value Generic Tier	001000	1	2	2	Value Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Value Generic Tier	2	Value Generic Tier																						Value Generic Tier				2.50	7.50	5.00	39.00	117.00	78.00	39.00					1.75	5.00	3.50	39.00	117.00	78.00	39.00	1	1	
S5601	106	0		29	10	S5601_106_0	2	2	4	3	Generic Tier	000100	1	2	2	Generic Tier	100011111110000111111				34	90	60	34	90	60	34					34	90	60	34	90	60	34	2	Generic Tier	2	Generic Tier																						Generic Tier				7.50	22.50	15.00	39.00	117.00	78.00	39.00					6.50	19.00	12.75	39.00	117.00	78.00	39.00	1	1	
S5601	106	0		29	10	S5601_106_0	2	3	4	3	Preferred Brand Tier	000001	1	2	2	Preferred Brand Tier																								Preferred Brand Tier		Preferred Brand Tier																						Preferred Brand Tier																						2		
S5601	106	0		29	10	S5601_106_0	2	4	4	3	Non-Preferred Brand Tier	100000	1	2	1	Non-Preferred Brand Tier																								Non-Preferred Brand Tier		Non-Preferred Brand Tier																						Non-Preferred Brand Tier																						2		
S5601	106	0		29	10	S5601_106_0	2	5	4	1	Specialty Tier	010010	1	1	2	Specialty Tier	100010010010000000000				34			34			34											34		Specialty Tier	1	Specialty Tier				33			33			33											33	Specialty Tier																								
S5609	001	0		29	10	S5609_001_0	6	4	3	1	Miscellaneous Injectables	110001		2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	27									27		27									27	Miscellaneous Injectables																								
S5609	001	0		29	10	S5609_001_0	6	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	61.00	183.00								61.00		61.00	183.00								61.00			
S5609	001	0		29	10	S5609_001_0	6	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
S5609	001	0		29	10	S5609_001_0	6	1	3	1	Generic	001000		2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
S5609	001	0		29	10	S5609_001_0	6	5	3	1	Specialty	110001		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	27									27		27									27	Specialty																								
S5609	002	0		29	10	S5609_002_0	3	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
S5609	002	0		29	10	S5609_002_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5609	002	0		29	10	S5609_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5609	002	0		29	10	S5609_002_0	3	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
S5609	002	0		29	10	S5609_002_0	3	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
S5609	002	0		29	10	S5609_002_0	3	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
S5609	002	0		29	10	S5609_002_0	3	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5609	002	0		29	10	S5609_002_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
S5609	002	0		29	10	S5609_002_0	3	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
S5609	002	0		29	10	S5609_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
S5617	003	0		29	10	S5617_003_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	003	0		29	10	S5617_003_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00									78.00				78.00	195.00		78.00	234.00		78.00			
S5617	003	0		29	10	S5617_003_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	32.00	96.00									32.00				32.00	80.00		32.00	96.00		32.00			
S5617	003	0		29	10	S5617_003_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	005	0		29	10	S5617_005_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	005	0		29	10	S5617_005_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	005	0		29	10	S5617_005_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	005	0		29	10	S5617_005_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	90.00	270.00									90.00				90.00	225.00		90.00	270.00		90.00			
S5617	008	0		29	10	S5617_008_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	008	0		29	10	S5617_008_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00			
S5617	008	0		29	10	S5617_008_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	77.00	231.00									77.00				77.00	192.50		77.00	231.00		77.00			
S5617	010	0		29	10	S5617_010_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	91.00	273.00									91.00				91.00	227.50		91.00	273.00		91.00			
S5617	010	0		29	10	S5617_010_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	010	0		29	10	S5617_010_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	010	0		29	10	S5617_010_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	013	0		29	10	S5617_013_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	013	0		29	10	S5617_013_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	013	0		29	10	S5617_013_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	74.00	222.00									74.00				74.00	185.00		74.00	222.00		74.00			
S5617	013	0		29	10	S5617_013_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	015	0		29	10	S5617_015_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	015	0		29	10	S5617_015_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	90.00	270.00									90.00				90.00	225.00		90.00	270.00		90.00			
S5617	015	0		29	10	S5617_015_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	37.00	111.00									37.00				37.00	92.50		37.00	111.00		37.00			
S5617	015	0		29	10	S5617_015_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	018	0		29	10	S5617_018_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	018	0		29	10	S5617_018_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00									29.00				29.00	72.50		29.00	87.00		29.00			
S5617	018	0		29	10	S5617_018_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	020	0		29	10	S5617_020_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00			
S5617	020	0		29	10	S5617_020_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	39.00	117.00									39.00				39.00	97.50		39.00	117.00		39.00			
S5617	020	0		29	10	S5617_020_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	020	0		29	10	S5617_020_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	025	0		29	10	S5617_025_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	78.00	234.00									78.00				78.00	195.00		78.00	234.00		78.00			
S5617	025	0		29	10	S5617_025_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	025	0		29	10	S5617_025_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	025	0		29	10	S5617_025_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	030	0		29	10	S5617_030_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	030	0		29	10	S5617_030_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	39.00	117.00									39.00				39.00	97.50		39.00	117.00		39.00			
S5617	030	0		29	10	S5617_030_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00			
S5617	030	0		29	10	S5617_030_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	035	0		29	10	S5617_035_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	035	0		29	10	S5617_035_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	37.00	111.00									37.00				37.00	92.50		37.00	111.00		37.00			
S5617	035	0		29	10	S5617_035_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	77.00	231.00									77.00				77.00	192.50		77.00	231.00		77.00			
S5617	035	0		29	10	S5617_035_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	040	0		29	10	S5617_040_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	91.00	273.00									91.00				91.00	227.50		91.00	273.00		91.00			
S5617	040	0		29	10	S5617_040_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
S5617	040	0		29	10	S5617_040_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	040	0		29	10	S5617_040_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	045	0		29	10	S5617_045_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	92.00	276.00									92.00				92.00	230.00		92.00	276.00		92.00			
S5617	045	0		29	10	S5617_045_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	37.00	111.00									37.00				37.00	92.50		37.00	111.00		37.00			
S5617	045	0		29	10	S5617_045_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	045	0		29	10	S5617_045_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	050	0		29	10	S5617_050_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	050	0		29	10	S5617_050_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	87.00	261.00									87.00				87.00	217.50		87.00	261.00		87.00			
S5617	050	0		29	10	S5617_050_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	050	0		29	10	S5617_050_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	053	0		29	10	S5617_053_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	053	0		29	10	S5617_053_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	76.00	228.00									76.00				76.00	190.00		76.00	228.00		76.00			
S5617	053	0		29	10	S5617_053_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00									29.00				29.00	72.50		29.00	87.00		29.00			
S5617	053	0		29	10	S5617_053_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	055	0		29	10	S5617_055_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
S5617	055	0		29	10	S5617_055_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00			
S5617	055	0		29	10	S5617_055_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	055	0		29	10	S5617_055_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	055	0		29	10	S5617_055_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	060	0		29	10	S5617_060_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	060	0		29	10	S5617_060_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	37.00	111.00									37.00				37.00	92.50		37.00	111.00		37.00			
S5617	060	0		29	10	S5617_060_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	84.00	252.00									84.00				84.00	210.00		84.00	252.00		84.00			
S5617	060	0		29	10	S5617_060_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	060	0		29	10	S5617_060_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	87.00	261.00									87.00				87.00	217.50		87.00	261.00		87.00			
S5617	065	0		29	10	S5617_065_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	41.00	123.00									41.00				41.00	102.50		41.00	123.00		41.00			
S5617	065	0		29	10	S5617_065_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	065	0		29	10	S5617_065_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	068	0		29	10	S5617_068_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	068	0		29	10	S5617_068_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	76.00	228.00									76.00				76.00	190.00		76.00	228.00		76.00			
S5617	068	0		29	10	S5617_068_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	34.00	102.00									34.00				34.00	85.00		34.00	102.00		34.00			
S5617	068	0		29	10	S5617_068_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	070	0		29	10	S5617_070_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	070	0		29	10	S5617_070_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	89.00	267.00									89.00				89.00	222.50		89.00	267.00		89.00			
S5617	070	0		29	10	S5617_070_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	070	0		29	10	S5617_070_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	075	0		29	10	S5617_075_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	075	0		29	10	S5617_075_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	075	0		29	10	S5617_075_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	84.00	252.00									84.00				84.00	210.00		84.00	252.00		84.00			
S5617	080	0		29	10	S5617_080_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	080	0		29	10	S5617_080_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	41.00	123.00									41.00				41.00	102.50		41.00	123.00		41.00			
S5617	080	0		29	10	S5617_080_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	080	0		29	10	S5617_080_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	92.00	276.00									92.00				92.00	230.00		92.00	276.00		92.00			
S5617	085	0		29	10	S5617_085_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	085	0		29	10	S5617_085_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	085	0		29	10	S5617_085_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	41.00	123.00									41.00				41.00	102.50		41.00	123.00		41.00			
S5617	085	0		29	10	S5617_085_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	87.00	261.00									87.00				87.00	217.50		87.00	261.00		87.00			
S5617	088	0		29	10	S5617_088_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	088	0		29	10	S5617_088_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	088	0		29	10	S5617_088_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	84.00	252.00									84.00				84.00	210.00		84.00	252.00		84.00			
S5617	090	0		29	10	S5617_090_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	090	0		29	10	S5617_090_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	84.00	252.00									84.00				84.00	210.00		84.00	252.00		84.00			
S5617	090	0		29	10	S5617_090_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	36.00	108.00									36.00				36.00	90.00		36.00	108.00		36.00			
S5617	090	0		29	10	S5617_090_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	090	0		29	10	S5617_090_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	095	0		29	10	S5617_095_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	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	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	095	0		29	10	S5617_095_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	095	0		29	10	S5617_095_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	100	0		29	10	S5617_100_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	100	0		29	10	S5617_100_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	83.00	249.00									83.00				83.00	207.50		83.00	249.00		83.00			
S5617	100	0		29	10	S5617_100_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	100	0		29	10	S5617_100_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	103	0		29	10	S5617_103_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00									29.00				29.00	72.50		29.00	87.00		29.00			
S5617	103	0		29	10	S5617_103_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	103	0		29	10	S5617_103_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	105	0		29	10	S5617_105_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	84.00	252.00									84.00				84.00	210.00		84.00	252.00		84.00			
S5617	105	0		29	10	S5617_105_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	105	0		29	10	S5617_105_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	105	0		29	10	S5617_105_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	108	0		29	10	S5617_108_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	108	0		29	10	S5617_108_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	108	0		29	10	S5617_108_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	108	0		29	10	S5617_108_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	77.00	231.00									77.00				77.00	192.50		77.00	231.00		77.00			
S5617	110	0		29	10	S5617_110_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	37.00	111.00									37.00				37.00	92.50		37.00	111.00		37.00			
S5617	110	0		29	10	S5617_110_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	93.00	279.00									93.00				93.00	232.50		93.00	279.00		93.00			
S5617	110	0		29	10	S5617_110_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	110	0		29	10	S5617_110_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	113	0		29	10	S5617_113_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	113	0		29	10	S5617_113_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	113	0		29	10	S5617_113_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	86.00	258.00									86.00				86.00	215.00		86.00	258.00		86.00			
S5617	115	0		29	10	S5617_115_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	115	0		29	10	S5617_115_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	98.00	294.00									98.00				98.00	245.00		98.00	294.00		98.00			
S5617	115	0		29	10	S5617_115_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	115	0		29	10	S5617_115_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	115	0		29	10	S5617_115_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	118	0		29	10	S5617_118_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	118	0		29	10	S5617_118_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	118	0		29	10	S5617_118_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	89.00	267.00									89.00				89.00	222.50		89.00	267.00		89.00			
S5617	120	0		29	10	S5617_120_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	81.00	243.00									81.00				81.00	202.50		81.00	243.00		81.00			
S5617	120	0		29	10	S5617_120_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	120	0		29	10	S5617_120_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	34.00	102.00									34.00				34.00	85.00		34.00	102.00		34.00			
S5617	120	0		29	10	S5617_120_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	123	0		29	10	S5617_123_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	123	0		29	10	S5617_123_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00									29.00				29.00	72.50		29.00	87.00		29.00			
S5617	123	0		29	10	S5617_123_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	123	0		29	10	S5617_123_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	90.00	270.00									90.00				90.00	225.00		90.00	270.00		90.00			
S5617	125	0		29	10	S5617_125_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	125	0		29	10	S5617_125_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	125	0		29	10	S5617_125_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	125	0		29	10	S5617_125_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00			
S5617	128	0		29	10	S5617_128_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	128	0		29	10	S5617_128_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	128	0		29	10	S5617_128_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00									70.00				70.00	175.00		70.00	210.00		70.00			
S5617	128	0		29	10	S5617_128_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	130	0		29	10	S5617_130_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00			
S5617	130	0		29	10	S5617_130_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	130	0		29	10	S5617_130_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	130	0		29	10	S5617_130_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	133	0		29	10	S5617_133_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	133	0		29	10	S5617_133_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00			
S5617	133	0		29	10	S5617_133_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	133	0		29	10	S5617_133_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	32.00	96.00									32.00				32.00	80.00		32.00	96.00		32.00			
S5617	135	0		29	10	S5617_135_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	135	0		29	10	S5617_135_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00			
S5617	135	0		29	10	S5617_135_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	39.00	117.00									39.00				39.00	97.50		39.00	117.00		39.00			
S5617	135	0		29	10	S5617_135_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	138	0		29	10	S5617_138_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00									29.00				29.00	72.50		29.00	87.00		29.00			
S5617	138	0		29	10	S5617_138_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00			
S5617	138	0		29	10	S5617_138_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	140	0		29	10	S5617_140_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	140	0		29	10	S5617_140_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	140	0		29	10	S5617_140_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00			
S5617	143	0		29	10	S5617_143_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	143	0		29	10	S5617_143_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00			
S5617	143	0		29	10	S5617_143_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	143	0		29	10	S5617_143_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	145	0		29	10	S5617_145_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	95.00	285.00									95.00				95.00	237.50		95.00	285.00		95.00			
S5617	145	0		29	10	S5617_145_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	40.00	120.00									40.00				40.00	100.00		40.00	120.00		40.00			
S5617	145	0		29	10	S5617_145_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	145	0		29	10	S5617_145_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	145	0		29	10	S5617_145_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	148	0		29	10	S5617_148_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00			
S5617	148	0		29	10	S5617_148_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00									78.00				78.00	195.00		78.00	234.00		78.00			
S5617	148	0		29	10	S5617_148_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	150	0		29	10	S5617_150_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	150	0		29	10	S5617_150_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	89.00	267.00									89.00				89.00	222.50		89.00	267.00		89.00			
S5617	150	0		29	10	S5617_150_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	153	0		29	10	S5617_153_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	153	0		29	10	S5617_153_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	92.00	276.00									92.00				92.00	230.00		92.00	276.00		92.00			
S5617	153	0		29	10	S5617_153_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	155	0		29	10	S5617_155_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	86.00	258.00									86.00				86.00	215.00		86.00	258.00		86.00			
S5617	155	0		29	10	S5617_155_0	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	155	0		29	10	S5617_155_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	37.00	111.00									37.00				37.00	92.50		37.00	111.00		37.00			
S5617	155	0		29	10	S5617_155_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	155	0		29	10	S5617_155_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00									0.00				0.00	0.00		0.00	0.00		0.00			
S5617	158	0		29	10	S5617_158_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	158	0		29	10	S5617_158_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00			
S5617	158	0		29	10	S5617_158_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00									75.00				75.00	187.50		75.00	225.00		75.00			
S5617	158	0		29	10	S5617_158_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	160	0		29	10	S5617_160_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	160	0		29	10	S5617_160_0	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	38.00	114.00									38.00				38.00	95.00		38.00	114.00		38.00			
S5617	160	0		29	10	S5617_160_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	163	0		29	10	S5617_163_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	163	0		29	10	S5617_163_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	163	0		29	10	S5617_163_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00			
S5617	165	0		29	10	S5617_165_0	2	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	2	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	165	0		29	10	S5617_165_0	2	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	2	Tier 4																						Tier 4	97.00	291.00									97.00				97.00	242.50		97.00	291.00		97.00			
S5617	165	0		29	10	S5617_165_0	2	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	42.00	126.00									42.00				42.00	105.00		42.00	126.00		42.00			
S5617	165	0		29	10	S5617_165_0	2	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	170	0		29	10	S5617_170_0	1	2	3	1	Tier 2	010010		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	8.00	24.00									8.00				8.00	20.00		8.00	24.00		8.00			
S5617	170	0		29	10	S5617_170_0	1	1	3	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	3	1	Tier 3	010001		2	2	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
S5617	170	0		29	10	S5617_170_0	1	4	3	1	Tier 4	110000		2	1	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	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	1	5	3	1	Tier 5	010010		1	2	Tier 5	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 5	1	Tier 5	25	25									25				25	25		25	25		25	Tier 5																								
S5617	171	0		29	10	S5617_171_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	171	0		29	10	S5617_171_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00			
S5617	171	0		29	10	S5617_171_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	171	0		29	10	S5617_171_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	171	0		29	10	S5617_171_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	171	0		29	10	S5617_171_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	172	0		29	10	S5617_172_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	172	0		29	10	S5617_172_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	172	0		29	10	S5617_172_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	172	0		29	10	S5617_172_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	172	0		29	10	S5617_172_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	173	0		29	10	S5617_173_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	173	0		29	10	S5617_173_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	173	0		29	10	S5617_173_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	173	0		29	10	S5617_173_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	173	0		29	10	S5617_173_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	173	0		29	10	S5617_173_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	174	0		29	10	S5617_174_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	174	0		29	10	S5617_174_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	174	0		29	10	S5617_174_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	174	0		29	10	S5617_174_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	175	0		29	10	S5617_175_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	175	0		29	10	S5617_175_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	175	0		29	10	S5617_175_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	175	0		29	10	S5617_175_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	175	0		29	10	S5617_175_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	175	0		29	10	S5617_175_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00			
S5617	176	0		29	10	S5617_176_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	176	0		29	10	S5617_176_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	176	0		29	10	S5617_176_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	176	0		29	10	S5617_176_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00			
S5617	176	0		29	10	S5617_176_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	176	0		29	10	S5617_176_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	177	0		29	10	S5617_177_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00									35.00				35.00	87.50		35.00	105.00		35.00			
S5617	177	0		29	10	S5617_177_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	177	0		29	10	S5617_177_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	177	0		29	10	S5617_177_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	177	0		29	10	S5617_177_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	177	0		29	10	S5617_177_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	178	0		29	10	S5617_178_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	178	0		29	10	S5617_178_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	178	0		29	10	S5617_178_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	178	0		29	10	S5617_178_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	178	0		29	10	S5617_178_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	178	0		29	10	S5617_178_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	179	0		29	10	S5617_179_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	179	0		29	10	S5617_179_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	179	0		29	10	S5617_179_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	179	0		29	10	S5617_179_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	179	0		29	10	S5617_179_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	180	0		29	10	S5617_180_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	180	0		29	10	S5617_180_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	180	0		29	10	S5617_180_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	180	0		29	10	S5617_180_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	181	0		29	10	S5617_181_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00			
S5617	181	0		29	10	S5617_181_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	181	0		29	10	S5617_181_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	181	0		29	10	S5617_181_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	181	0		29	10	S5617_181_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	181	0		29	10	S5617_181_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	182	0		29	10	S5617_182_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	182	0		29	10	S5617_182_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	182	0		29	10	S5617_182_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	182	0		29	10	S5617_182_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	182	0		29	10	S5617_182_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	182	0		29	10	S5617_182_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00			
S5617	182	0		29	10	S5617_182_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	183	0		29	10	S5617_183_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	183	0		29	10	S5617_183_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	183	0		29	10	S5617_183_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	183	0		29	10	S5617_183_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	184	0		29	10	S5617_184_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	184	0		29	10	S5617_184_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	184	0		29	10	S5617_184_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	184	0		29	10	S5617_184_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	184	0		29	10	S5617_184_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	185	0		29	10	S5617_185_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00			
S5617	185	0		29	10	S5617_185_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	185	0		29	10	S5617_185_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	185	0		29	10	S5617_185_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	185	0		29	10	S5617_185_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	185	0		29	10	S5617_185_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	186	0		29	10	S5617_186_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00			
S5617	186	0		29	10	S5617_186_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	186	0		29	10	S5617_186_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	186	0		29	10	S5617_186_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	186	0		29	10	S5617_186_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	186	0		29	10	S5617_186_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	187	0		29	10	S5617_187_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	187	0		29	10	S5617_187_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	187	0		29	10	S5617_187_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	187	0		29	10	S5617_187_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	187	0		29	10	S5617_187_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	188	0		29	10	S5617_188_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00			
S5617	188	0		29	10	S5617_188_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	188	0		29	10	S5617_188_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	188	0		29	10	S5617_188_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	188	0		29	10	S5617_188_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	188	0		29	10	S5617_188_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	189	0		29	10	S5617_189_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	189	0		29	10	S5617_189_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	189	0		29	10	S5617_189_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	189	0		29	10	S5617_189_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	189	0		29	10	S5617_189_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	190	0		29	10	S5617_190_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	190	0		29	10	S5617_190_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	190	0		29	10	S5617_190_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	190	0		29	10	S5617_190_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	190	0		29	10	S5617_190_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	191	0		29	10	S5617_191_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	191	0		29	10	S5617_191_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	191	0		29	10	S5617_191_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	191	0		29	10	S5617_191_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	191	0		29	10	S5617_191_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	192	0		29	10	S5617_192_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	192	0		29	10	S5617_192_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	192	0		29	10	S5617_192_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	192	0		29	10	S5617_192_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	192	0		29	10	S5617_192_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	192	0		29	10	S5617_192_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	193	0		29	10	S5617_193_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	193	0		29	10	S5617_193_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	193	0		29	10	S5617_193_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	193	0		29	10	S5617_193_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	194	0		29	10	S5617_194_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	194	0		29	10	S5617_194_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	194	0		29	10	S5617_194_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	194	0		29	10	S5617_194_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	194	0		29	10	S5617_194_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	194	0		29	10	S5617_194_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	195	0		29	10	S5617_195_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	195	0		29	10	S5617_195_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	195	0		29	10	S5617_195_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	195	0		29	10	S5617_195_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	196	0		29	10	S5617_196_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	196	0		29	10	S5617_196_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	196	0		29	10	S5617_196_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	196	0		29	10	S5617_196_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	196	0		29	10	S5617_196_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	197	0		29	10	S5617_197_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00			
S5617	197	0		29	10	S5617_197_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	197	0		29	10	S5617_197_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	197	0		29	10	S5617_197_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	197	0		29	10	S5617_197_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	197	0		29	10	S5617_197_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	197	0		29	10	S5617_197_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	198	0		29	10	S5617_198_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	198	0		29	10	S5617_198_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	198	0		29	10	S5617_198_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	198	0		29	10	S5617_198_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	198	0		29	10	S5617_198_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	199	0		29	10	S5617_199_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	199	0		29	10	S5617_199_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	199	0		29	10	S5617_199_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	199	0		29	10	S5617_199_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	199	0		29	10	S5617_199_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	200	0		29	10	S5617_200_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	200	0		29	10	S5617_200_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	200	0		29	10	S5617_200_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	200	0		29	10	S5617_200_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	201	0		29	10	S5617_201_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	201	0		29	10	S5617_201_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	201	0		29	10	S5617_201_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	201	0		29	10	S5617_201_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	201	0		29	10	S5617_201_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	201	0		29	10	S5617_201_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	202	0		29	10	S5617_202_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	202	0		29	10	S5617_202_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	202	0		29	10	S5617_202_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00									60.00				60.00	150.00		60.00	180.00		60.00			
S5617	202	0		29	10	S5617_202_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	202	0		29	10	S5617_202_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	202	0		29	10	S5617_202_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	203	0		29	10	S5617_203_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	203	0		29	10	S5617_203_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	203	0		29	10	S5617_203_0	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	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	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	203	0		29	10	S5617_203_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	204	0		29	10	S5617_204_0	1	3	4	1	Tier 3	110000	1	2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	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	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	33	33									33				33	33		33	33		33	Tier 4																								
S5617	204	0		29	10	S5617_204_0	1	2	4	1	Tier 2	010001	1	2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 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	1	1	4	1	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	6.00	18.00									6.00				6.00	15.00		6.00	18.00		6.00			
S5617	204	0		29	10	S5617_204_0	1	1	4	3	Tier 1	010010	1	2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	1	Tier 1	25	25									25				25	25		40	40		25	Tier 1																						1	2	00001000
S5617	204	0		29	10	S5617_204_0	1	2	4	3	Tier 2	010001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5617	204	0		29	10	S5617_204_0	1	3	4	3	Tier 3	110000	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5617	204	0		29	10	S5617_204_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5617	214	0		29	10	S5617_214_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00			
S5617	214	0		29	10	S5617_214_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00			
S5617	214	0		29	10	S5617_214_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	214	0		29	10	S5617_214_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	215	0		29	10	S5617_215_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	215	0		29	10	S5617_215_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	215	0		29	10	S5617_215_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	90.00	270.00									90.00				90.00	225.00		90.00	270.00		90.00			
S5617	215	0		29	10	S5617_215_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	216	0		29	10	S5617_216_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	88.00	264.00									88.00				88.00	220.00		88.00	264.00		88.00			
S5617	216	0		29	10	S5617_216_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	29.00	87.00									29.00				29.00	72.50		29.00	87.00		29.00			
S5617	216	0		29	10	S5617_216_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	216	0		29	10	S5617_216_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	217	0		29	10	S5617_217_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	217	0		29	10	S5617_217_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	217	0		29	10	S5617_217_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00			
S5617	217	0		29	10	S5617_217_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	218	0		29	10	S5617_218_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	218	0		29	10	S5617_218_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	218	0		29	10	S5617_218_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	218	0		29	10	S5617_218_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	77.00	231.00									77.00				77.00	192.50		77.00	231.00		77.00			
S5617	219	0		29	10	S5617_219_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	219	0		29	10	S5617_219_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00									80.00				80.00	200.00		80.00	240.00		80.00			
S5617	219	0		29	10	S5617_219_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	219	0		29	10	S5617_219_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	220	0		29	10	S5617_220_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	220	0		29	10	S5617_220_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	220	0		29	10	S5617_220_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	79.00	237.00									79.00				79.00	197.50		79.00	237.00		79.00			
S5617	220	0		29	10	S5617_220_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	221	0		29	10	S5617_221_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	221	0		29	10	S5617_221_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00									33.00				33.00	82.50		33.00	99.00		33.00			
S5617	221	0		29	10	S5617_221_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00									85.00				85.00	212.50		85.00	255.00		85.00			
S5617	221	0		29	10	S5617_221_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	222	0		29	10	S5617_222_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	86.00	258.00									86.00				86.00	215.00		86.00	258.00		86.00			
S5617	222	0		29	10	S5617_222_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	30.00	90.00									30.00				30.00	75.00		30.00	90.00		30.00			
S5617	222	0		29	10	S5617_222_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	222	0		29	10	S5617_222_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	223	0		29	10	S5617_223_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	223	0		29	10	S5617_223_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	34.00	102.00									34.00				34.00	85.00		34.00	102.00		34.00			
S5617	223	0		29	10	S5617_223_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	87.00	261.00									87.00				87.00	217.50		87.00	261.00		87.00			
S5617	223	0		29	10	S5617_223_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	224	0		29	10	S5617_224_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	86.00	258.00									86.00				86.00	215.00		86.00	258.00		86.00			
S5617	224	0		29	10	S5617_224_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	32.00	96.00									32.00				32.00	80.00		32.00	96.00		32.00			
S5617	224	0		29	10	S5617_224_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	224	0		29	10	S5617_224_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	225	0		29	10	S5617_225_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	225	0		29	10	S5617_225_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00			
S5617	225	0		29	10	S5617_225_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	82.00	246.00									82.00				82.00	205.00		82.00	246.00		82.00			
S5617	225	0		29	10	S5617_225_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	226	0		29	10	S5617_226_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	226	0		29	10	S5617_226_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	31.00	93.00									31.00				31.00	77.50		31.00	93.00		31.00			
S5617	226	0		29	10	S5617_226_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5617	226	0		29	10	S5617_226_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	74.00	222.00									74.00				74.00	185.00		74.00	222.00		74.00			
S5617	227	0		29	10	S5617_227_0	1	1	2	1	Tier 1	010010		2	2	Tier 1	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00									3.00				3.00	7.50		3.00	9.00		3.00			
S5617	227	0		29	10	S5617_227_0	1	3	2	1	Tier 3	110000		2	1	Tier 3	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 3	2	Tier 3																						Tier 3	71.00	213.00									71.00				71.00	177.50		71.00	213.00		71.00			
S5617	227	0		29	10	S5617_227_0	1	2	2	1	Tier 2	010001		2	2	Tier 2	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 2	2	Tier 2																						Tier 2	27.00	81.00									27.00				27.00	67.50		27.00	81.00		27.00			
S5617	227	0		29	10	S5617_227_0	1	4	2	1	Tier 4	010010		1	2	Tier 4	111000000001000110110	30	90									10				30	90		30	90		31	1	Tier 4	1	Tier 4	25	25									25				25	25		25	25		25	Tier 4																								
S5644	004	0		29	10	S5644_004_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00			
S5644	004	0		29	10	S5644_004_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	004	0		29	10	S5644_004_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	004	0		29	10	S5644_004_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	005	0		29	10	S5644_005_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.25	12.75								4.25			12.75								4.25			
S5644	005	0		29	10	S5644_005_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	005	0		29	10	S5644_005_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	005	0		29	10	S5644_005_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	012	0		29	10	S5644_012_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
S5644	012	0		29	10	S5644_012_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	012	0		29	10	S5644_012_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	012	0		29	10	S5644_012_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	045	0		29	10	S5644_045_0	4	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	045	0		29	10	S5644_045_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	045	0		29	10	S5644_045_0	4	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	045	0		29	10	S5644_045_0	4	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	045	0		29	10	S5644_045_0	4	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	047	0		29	10	S5644_047_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	047	0		29	10	S5644_047_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	047	0		29	10	S5644_047_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	047	0		29	10	S5644_047_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	047	0		29	10	S5644_047_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	048	0		29	10	S5644_048_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	048	0		29	10	S5644_048_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	048	0		29	10	S5644_048_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	048	0		29	10	S5644_048_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	048	0		29	10	S5644_048_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	049	0		29	10	S5644_049_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	049	0		29	10	S5644_049_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	049	0		29	10	S5644_049_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	049	0		29	10	S5644_049_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	049	0		29	10	S5644_049_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	050	0		29	10	S5644_050_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	050	0		29	10	S5644_050_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	050	0		29	10	S5644_050_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	050	0		29	10	S5644_050_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	050	0		29	10	S5644_050_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	051	0		29	10	S5644_051_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	051	0		29	10	S5644_051_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	051	0		29	10	S5644_051_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	051	0		29	10	S5644_051_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	051	0		29	10	S5644_051_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	052	0		29	10	S5644_052_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	052	0		29	10	S5644_052_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	052	0		29	10	S5644_052_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	052	0		29	10	S5644_052_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	052	0		29	10	S5644_052_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	053	0		29	10	S5644_053_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	053	0		29	10	S5644_053_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	053	0		29	10	S5644_053_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	053	0		29	10	S5644_053_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	053	0		29	10	S5644_053_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	054	0		29	10	S5644_054_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	054	0		29	10	S5644_054_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	054	0		29	10	S5644_054_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	054	0		29	10	S5644_054_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	054	0		29	10	S5644_054_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	055	0		29	10	S5644_055_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	055	0		29	10	S5644_055_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	055	0		29	10	S5644_055_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	055	0		29	10	S5644_055_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	055	0		29	10	S5644_055_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	056	0		29	10	S5644_056_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	056	0		29	10	S5644_056_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	056	0		29	10	S5644_056_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	056	0		29	10	S5644_056_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	056	0		29	10	S5644_056_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	057	0		29	10	S5644_057_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	057	0		29	10	S5644_057_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	057	0		29	10	S5644_057_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	057	0		29	10	S5644_057_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	057	0		29	10	S5644_057_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	058	0		29	10	S5644_058_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	058	0		29	10	S5644_058_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	058	0		29	10	S5644_058_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	058	0		29	10	S5644_058_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	058	0		29	10	S5644_058_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	059	0		29	10	S5644_059_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	059	0		29	10	S5644_059_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	059	0		29	10	S5644_059_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	059	0		29	10	S5644_059_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	059	0		29	10	S5644_059_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	060	0		29	10	S5644_060_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	060	0		29	10	S5644_060_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	060	0		29	10	S5644_060_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	060	0		29	10	S5644_060_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	060	0		29	10	S5644_060_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	061	0		29	10	S5644_061_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	061	0		29	10	S5644_061_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	061	0		29	10	S5644_061_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	061	0		29	10	S5644_061_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	061	0		29	10	S5644_061_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	062	0		29	10	S5644_062_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	062	0		29	10	S5644_062_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	062	0		29	10	S5644_062_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	062	0		29	10	S5644_062_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	062	0		29	10	S5644_062_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	063	0		29	10	S5644_063_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	063	0		29	10	S5644_063_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	063	0		29	10	S5644_063_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	063	0		29	10	S5644_063_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	063	0		29	10	S5644_063_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	064	0		29	10	S5644_064_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	064	0		29	10	S5644_064_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	064	0		29	10	S5644_064_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	064	0		29	10	S5644_064_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	064	0		29	10	S5644_064_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	065	0		29	10	S5644_065_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	065	0		29	10	S5644_065_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	065	0		29	10	S5644_065_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	065	0		29	10	S5644_065_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	065	0		29	10	S5644_065_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	067	0		29	10	S5644_067_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.25	12.75								4.25			12.75								4.25			
S5644	067	0		29	10	S5644_067_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	067	0		29	10	S5644_067_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	067	0		29	10	S5644_067_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	068	0		29	10	S5644_068_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	068	0		29	10	S5644_068_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	068	0		29	10	S5644_068_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.75	14.25								4.75			14.25								4.75			
S5644	068	0		29	10	S5644_068_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	071	0		29	10	S5644_071_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	071	0		29	10	S5644_071_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			15.00								5.00			
S5644	071	0		29	10	S5644_071_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	071	0		29	10	S5644_071_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	072	0		29	10	S5644_072_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	072	0		29	10	S5644_072_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	072	0		29	10	S5644_072_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S5644	072	0		29	10	S5644_072_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	073	0		29	10	S5644_073_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	073	0		29	10	S5644_073_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	073	0		29	10	S5644_073_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.75	11.25								3.75			11.25								3.75			
S5644	073	0		29	10	S5644_073_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	074	0		29	10	S5644_074_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.75	11.25								3.75			11.25								3.75			
S5644	074	0		29	10	S5644_074_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	074	0		29	10	S5644_074_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	074	0		29	10	S5644_074_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	075	0		29	10	S5644_075_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.25	9.75								3.25			9.75								3.25			
S5644	075	0		29	10	S5644_075_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	075	0		29	10	S5644_075_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	075	0		29	10	S5644_075_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	076	0		29	10	S5644_076_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	076	0		29	10	S5644_076_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	076	0		29	10	S5644_076_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	076	0		29	10	S5644_076_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S5644	078	0		29	10	S5644_078_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	078	0		29	10	S5644_078_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.25	12.75								4.25			12.75								4.25			
S5644	078	0		29	10	S5644_078_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	078	0		29	10	S5644_078_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	079	0		29	10	S5644_079_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	079	0		29	10	S5644_079_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	079	0		29	10	S5644_079_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S5644	079	0		29	10	S5644_079_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	080	0		29	10	S5644_080_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	080	0		29	10	S5644_080_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	080	0		29	10	S5644_080_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
S5644	080	0		29	10	S5644_080_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	081	0		29	10	S5644_081_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.50	16.50								5.50			16.50								5.50			
S5644	081	0		29	10	S5644_081_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	081	0		29	10	S5644_081_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	081	0		29	10	S5644_081_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	082	0		29	10	S5644_082_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	082	0		29	10	S5644_082_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	082	0		29	10	S5644_082_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			18.00								6.00			
S5644	082	0		29	10	S5644_082_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	083	0		29	10	S5644_083_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	083	0		29	10	S5644_083_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	083	0		29	10	S5644_083_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.75	11.25								3.75			11.25								3.75			
S5644	083	0		29	10	S5644_083_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	084	0		29	10	S5644_084_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	084	0		29	10	S5644_084_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	084	0		29	10	S5644_084_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S5644	084	0		29	10	S5644_084_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	085	0		29	10	S5644_085_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	085	0		29	10	S5644_085_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.25	9.75								3.25			9.75								3.25			
S5644	085	0		29	10	S5644_085_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	085	0		29	10	S5644_085_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	087	0		29	10	S5644_087_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	087	0		29	10	S5644_087_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	087	0		29	10	S5644_087_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
S5644	087	0		29	10	S5644_087_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	174	0		29	10	S5644_174_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	174	0		29	10	S5644_174_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	174	0		29	10	S5644_174_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	174	0		29	10	S5644_174_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	174	0		29	10	S5644_174_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	175	0		29	10	S5644_175_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	175	0		29	10	S5644_175_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	175	0		29	10	S5644_175_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	175	0		29	10	S5644_175_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	175	0		29	10	S5644_175_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	176	0		29	10	S5644_176_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	176	0		29	10	S5644_176_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	176	0		29	10	S5644_176_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	176	0		29	10	S5644_176_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	176	0		29	10	S5644_176_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	177	0		29	10	S5644_177_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	177	0		29	10	S5644_177_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	177	0		29	10	S5644_177_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	177	0		29	10	S5644_177_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	177	0		29	10	S5644_177_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	178	0		29	10	S5644_178_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	178	0		29	10	S5644_178_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	178	0		29	10	S5644_178_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	178	0		29	10	S5644_178_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	178	0		29	10	S5644_178_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	179	0		29	10	S5644_179_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	179	0		29	10	S5644_179_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	179	0		29	10	S5644_179_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	179	0		29	10	S5644_179_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	179	0		29	10	S5644_179_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	180	0		29	10	S5644_180_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	180	0		29	10	S5644_180_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	180	0		29	10	S5644_180_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	180	0		29	10	S5644_180_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	180	0		29	10	S5644_180_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	181	0		29	10	S5644_181_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	181	0		29	10	S5644_181_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	181	0		29	10	S5644_181_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	181	0		29	10	S5644_181_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	181	0		29	10	S5644_181_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	182	0		29	10	S5644_182_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	182	0		29	10	S5644_182_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	182	0		29	10	S5644_182_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	182	0		29	10	S5644_182_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	182	0		29	10	S5644_182_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	183	0		29	10	S5644_183_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	183	0		29	10	S5644_183_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	183	0		29	10	S5644_183_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	183	0		29	10	S5644_183_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	183	0		29	10	S5644_183_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	184	0		29	10	S5644_184_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	184	0		29	10	S5644_184_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	184	0		29	10	S5644_184_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	184	0		29	10	S5644_184_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	184	0		29	10	S5644_184_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	185	0		29	10	S5644_185_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	185	0		29	10	S5644_185_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	185	0		29	10	S5644_185_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	185	0		29	10	S5644_185_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	185	0		29	10	S5644_185_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	186	0		29	10	S5644_186_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	186	0		29	10	S5644_186_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	186	0		29	10	S5644_186_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	186	0		29	10	S5644_186_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	186	0		29	10	S5644_186_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	187	0		29	10	S5644_187_0	3	1	4	1	Value Generic	001000	1	2	2	Value Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Value Generic	2	Value Generic																						Value Generic				2.50	7.50		5.00	15.00		5.00						5.00			15.00		5.00			
S5644	187	0		29	10	S5644_187_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			31		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5644	187	0		29	10	S5644_187_0	3	2	4	1	Generic	010000	1	2	2	Generic	100011011010000010010				30	90		30	90		30						90			90		31	2	Generic	2	Generic																						Generic				5.00	15.00		5.00	15.00		5.00						10.00			15.00		5.00			
S5644	187	0		29	10	S5644_187_0	3	5	4	1	Non-Preferred	100100	1	2	1	Non-Preferred	100011011010000010010				30	90		30	90		30						90			90		31	2	Non-Preferred	1	Non-Preferred				45	45		45	45		45						45			45		45	Non-Preferred																								
S5644	187	0		29	10	S5644_187_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010000010010				30	90		30	90		30						90			90		31	2	Preferred Brand	1	Preferred Brand				33	33		33	33		33						33			33		33	Preferred Brand																								
S5644	188	0		29	10	S5644_188_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	188	0		29	10	S5644_188_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	188	0		29	10	S5644_188_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S5644	188	0		29	10	S5644_188_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	189	0		29	10	S5644_189_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.50	13.50								4.50			13.50								4.50			
S5644	189	0		29	10	S5644_189_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	189	0		29	10	S5644_189_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	189	0		29	10	S5644_189_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	190	0		29	10	S5644_190_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	190	0		29	10	S5644_190_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	190	0		29	10	S5644_190_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	190	0		29	10	S5644_190_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.25	15.75								5.25			15.75								5.25			
S5644	191	0		29	10	S5644_191_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	191	0		29	10	S5644_191_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	191	0		29	10	S5644_191_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.75	14.25								4.75			14.25								4.75			
S5644	191	0		29	10	S5644_191_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	192	0		29	10	S5644_192_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	192	0		29	10	S5644_192_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	192	0		29	10	S5644_192_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	192	0		29	10	S5644_192_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.75	17.25								5.75			17.25								5.75			
S5644	193	0		29	10	S5644_193_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	193	0		29	10	S5644_193_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.25	9.75								3.25			9.75								3.25			
S5644	193	0		29	10	S5644_193_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	193	0		29	10	S5644_193_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	194	0		29	10	S5644_194_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	194	0		29	10	S5644_194_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.25	9.75								3.25			9.75								3.25			
S5644	194	0		29	10	S5644_194_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	194	0		29	10	S5644_194_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	195	0		29	10	S5644_195_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	195	0		29	10	S5644_195_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	195	0		29	10	S5644_195_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	195	0		29	10	S5644_195_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.50	10.50								3.50			10.50								3.50			
S5644	196	0		29	10	S5644_196_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	196	0		29	10	S5644_196_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	196	0		29	10	S5644_196_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	196	0		29	10	S5644_196_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.25	12.75								4.25			12.75								4.25			
S5644	197	0		29	10	S5644_197_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	197	0		29	10	S5644_197_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	197	0		29	10	S5644_197_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.25	12.75								4.25			12.75								4.25			
S5644	197	0		29	10	S5644_197_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	198	0		29	10	S5644_198_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	198	0		29	10	S5644_198_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	198	0		29	10	S5644_198_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	198	0		29	10	S5644_198_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S5644	199	0		29	10	S5644_199_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.75	14.25								4.75			14.25								4.75			
S5644	199	0		29	10	S5644_199_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	199	0		29	10	S5644_199_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	199	0		29	10	S5644_199_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	200	0		29	10	S5644_200_0	3	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.25	12.75								4.25			12.75								4.25			
S5644	200	0		29	10	S5644_200_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	200	0		29	10	S5644_200_0	3	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	200	0		29	10	S5644_200_0	3	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5644	201	0		29	10	S5644_201_0	4	1	2	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	2.25	6.75								2.25			6.75								2.25			
S5644	201	0		29	10	S5644_201_0	4	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5644	201	0		29	10	S5644_201_0	4	3	2	1	Specialty	010010		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	25									25		25									25	Specialty																								
S5644	201	0		29	10	S5644_201_0	4	4	2	1	Non-Preferred	100100		2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	2	Non-Preferred	1	Non-Preferred	45	45								45			45								45	Non-Preferred																								
S5660	001	0		29	10	S5660_001_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	001	0		29	10	S5660_001_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	001	0		29	10	S5660_001_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	001	0		29	10	S5660_001_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	003	0		29	10	S5660_003_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	003	0		29	10	S5660_003_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	003	0		29	10	S5660_003_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	003	0		29	10	S5660_003_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	004	0		29	10	S5660_004_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	004	0		29	10	S5660_004_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	004	0		29	10	S5660_004_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	004	0		29	10	S5660_004_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00			
S5660	005	0		29	10	S5660_005_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	005	0		29	10	S5660_005_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	005	0		29	10	S5660_005_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	005	0		29	10	S5660_005_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	006	0		29	10	S5660_006_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	006	0		29	10	S5660_006_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	006	0		29	10	S5660_006_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00			
S5660	006	0		29	10	S5660_006_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	007	0		29	10	S5660_007_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	007	0		29	10	S5660_007_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	007	0		29	10	S5660_007_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	007	0		29	10	S5660_007_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00			
S5660	008	0		29	10	S5660_008_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	008	0		29	10	S5660_008_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	008	0		29	10	S5660_008_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	008	0		29	10	S5660_008_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	009	0		29	10	S5660_009_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	009	0		29	10	S5660_009_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	009	0		29	10	S5660_009_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	009	0		29	10	S5660_009_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	010	0		29	10	S5660_010_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	010	0		29	10	S5660_010_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	010	0		29	10	S5660_010_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	010	0		29	10	S5660_010_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	012	0		29	10	S5660_012_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	012	0		29	10	S5660_012_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	012	0		29	10	S5660_012_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	012	0		29	10	S5660_012_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	013	0		29	10	S5660_013_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	013	0		29	10	S5660_013_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	013	0		29	10	S5660_013_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	013	0		29	10	S5660_013_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	014	0		29	10	S5660_014_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	014	0		29	10	S5660_014_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	014	0		29	10	S5660_014_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	014	0		29	10	S5660_014_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	015	0		29	10	S5660_015_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	015	0		29	10	S5660_015_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	015	0		29	10	S5660_015_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	015	0		29	10	S5660_015_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	016	0		29	10	S5660_016_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	016	0		29	10	S5660_016_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	016	0		29	10	S5660_016_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	016	0		29	10	S5660_016_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	017	0		29	10	S5660_017_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	017	0		29	10	S5660_017_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	017	0		29	10	S5660_017_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	017	0		29	10	S5660_017_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	018	0		29	10	S5660_018_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	018	0		29	10	S5660_018_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	018	0		29	10	S5660_018_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	018	0		29	10	S5660_018_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	019	0		29	10	S5660_019_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	019	0		29	10	S5660_019_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	019	0		29	10	S5660_019_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00			
S5660	019	0		29	10	S5660_019_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	020	0		29	10	S5660_020_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	020	0		29	10	S5660_020_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	020	0		29	10	S5660_020_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00			
S5660	020	0		29	10	S5660_020_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	021	0		29	10	S5660_021_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	021	0		29	10	S5660_021_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	021	0		29	10	S5660_021_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	021	0		29	10	S5660_021_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00						90.00			108.00		36.00			
S5660	022	0		29	10	S5660_022_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	022	0		29	10	S5660_022_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	022	0		29	10	S5660_022_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	022	0		29	10	S5660_022_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	023	0		29	10	S5660_023_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	023	0		29	10	S5660_023_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	023	0		29	10	S5660_023_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	023	0		29	10	S5660_023_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	024	0		29	10	S5660_024_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	024	0		29	10	S5660_024_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	111.00								37.00						92.50			111.00		37.00			
S5660	024	0		29	10	S5660_024_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	024	0		29	10	S5660_024_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	025	0		29	10	S5660_025_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	025	0		29	10	S5660_025_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	025	0		29	10	S5660_025_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	025	0		29	10	S5660_025_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	026	0		29	10	S5660_026_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	026	0		29	10	S5660_026_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	114.00								38.00						95.00			114.00		38.00			
S5660	026	0		29	10	S5660_026_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	026	0		29	10	S5660_026_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	027	0		29	10	S5660_027_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	027	0		29	10	S5660_027_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	027	0		29	10	S5660_027_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	027	0		29	10	S5660_027_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	028	0		29	10	S5660_028_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	028	0		29	10	S5660_028_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	028	0		29	10	S5660_028_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	028	0		29	10	S5660_028_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	029	0		29	10	S5660_029_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	029	0		29	10	S5660_029_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	029	0		29	10	S5660_029_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	029	0		29	10	S5660_029_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	030	0		29	10	S5660_030_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	030	0		29	10	S5660_030_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	030	0		29	10	S5660_030_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	030	0		29	10	S5660_030_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	031	0		29	10	S5660_031_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	031	0		29	10	S5660_031_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	031	0		29	10	S5660_031_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	031	0		29	10	S5660_031_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	032	0		29	10	S5660_032_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	032	0		29	10	S5660_032_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	032	0		29	10	S5660_032_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	032	0		29	10	S5660_032_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	033	0		29	10	S5660_033_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	033	0		29	10	S5660_033_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	033	0		29	10	S5660_033_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	033	0		29	10	S5660_033_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	034	0		29	10	S5660_034_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	034	0		29	10	S5660_034_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	034	0		29	10	S5660_034_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	034	0		29	10	S5660_034_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	035	0		29	10	S5660_035_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	035	0		29	10	S5660_035_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	035	0		29	10	S5660_035_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	035	0		29	10	S5660_035_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	103	0		29	10	S5660_103_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5660	103	0		29	10	S5660_103_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	103	0		29	10	S5660_103_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5660	103	0		29	10	S5660_103_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5660	172	0		29	10	S5660_172_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	172	0		29	10	S5660_172_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	172	0		29	10	S5660_172_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	172	0		29	10	S5660_172_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	172	0		29	10	S5660_172_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	172	0		29	10	S5660_172_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	172	0		29	10	S5660_172_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	173	0		29	10	S5660_173_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	173	0		29	10	S5660_173_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	173	0		29	10	S5660_173_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	173	0		29	10	S5660_173_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	173	0		29	10	S5660_173_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	173	0		29	10	S5660_173_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	174	0		29	10	S5660_174_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	174	0		29	10	S5660_174_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	174	0		29	10	S5660_174_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	174	0		29	10	S5660_174_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	174	0		29	10	S5660_174_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	174	0		29	10	S5660_174_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	174	0		29	10	S5660_174_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	175	0		29	10	S5660_175_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	175	0		29	10	S5660_175_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	175	0		29	10	S5660_175_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	175	0		29	10	S5660_175_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	175	0		29	10	S5660_175_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	175	0		29	10	S5660_175_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	176	0		29	10	S5660_176_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	176	0		29	10	S5660_176_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	176	0		29	10	S5660_176_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	176	0		29	10	S5660_176_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	176	0		29	10	S5660_176_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	176	0		29	10	S5660_176_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	176	0		29	10	S5660_176_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	177	0		29	10	S5660_177_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	177	0		29	10	S5660_177_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	177	0		29	10	S5660_177_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	177	0		29	10	S5660_177_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	177	0		29	10	S5660_177_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	177	0		29	10	S5660_177_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5660	177	0		29	10	S5660_177_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	177	0		29	10	S5660_177_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	178	0		29	10	S5660_178_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	178	0		29	10	S5660_178_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	178	0		29	10	S5660_178_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	178	0		29	10	S5660_178_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	178	0		29	10	S5660_178_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	178	0		29	10	S5660_178_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	178	0		29	10	S5660_178_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	179	0		29	10	S5660_179_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	179	0		29	10	S5660_179_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	179	0		29	10	S5660_179_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	179	0		29	10	S5660_179_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	179	0		29	10	S5660_179_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	179	0		29	10	S5660_179_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	179	0		29	10	S5660_179_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	180	0		29	10	S5660_180_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	180	0		29	10	S5660_180_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	180	0		29	10	S5660_180_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	180	0		29	10	S5660_180_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	180	0		29	10	S5660_180_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	180	0		29	10	S5660_180_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	180	0		29	10	S5660_180_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	181	0		29	10	S5660_181_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	181	0		29	10	S5660_181_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	181	0		29	10	S5660_181_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	181	0		29	10	S5660_181_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	181	0		29	10	S5660_181_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	181	0		29	10	S5660_181_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	181	0		29	10	S5660_181_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	182	0		29	10	S5660_182_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	182	0		29	10	S5660_182_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	182	0		29	10	S5660_182_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	182	0		29	10	S5660_182_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	182	0		29	10	S5660_182_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	182	0		29	10	S5660_182_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	182	0		29	10	S5660_182_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
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																						2		
S5660	183	0		29	10	S5660_183_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	183	0		29	10	S5660_183_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	183	0		29	10	S5660_183_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	183	0		29	10	S5660_183_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	183	0		29	10	S5660_183_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	183	0		29	10	S5660_183_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	183	0		29	10	S5660_183_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	184	0		29	10	S5660_184_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	184	0		29	10	S5660_184_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	184	0		29	10	S5660_184_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
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																						2		
S5660	184	0		29	10	S5660_184_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	184	0		29	10	S5660_184_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	184	0		29	10	S5660_184_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	184	0		29	10	S5660_184_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	185	0		29	10	S5660_185_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	185	0		29	10	S5660_185_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	185	0		29	10	S5660_185_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	185	0		29	10	S5660_185_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	185	0		29	10	S5660_185_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	185	0		29	10	S5660_185_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	185	0		29	10	S5660_185_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
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																						2		
S5660	186	0		29	10	S5660_186_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	186	0		29	10	S5660_186_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	186	0		29	10	S5660_186_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	186	0		29	10	S5660_186_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	186	0		29	10	S5660_186_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	186	0		29	10	S5660_186_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	187	0		29	10	S5660_187_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	187	0		29	10	S5660_187_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	187	0		29	10	S5660_187_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	187	0		29	10	S5660_187_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	187	0		29	10	S5660_187_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	187	0		29	10	S5660_187_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	187	0		29	10	S5660_187_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	188	0		29	10	S5660_188_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	188	0		29	10	S5660_188_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	188	0		29	10	S5660_188_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	188	0		29	10	S5660_188_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	188	0		29	10	S5660_188_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	188	0		29	10	S5660_188_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	188	0		29	10	S5660_188_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	189	0		29	10	S5660_189_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	189	0		29	10	S5660_189_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	189	0		29	10	S5660_189_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	189	0		29	10	S5660_189_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	189	0		29	10	S5660_189_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	189	0		29	10	S5660_189_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	189	0		29	10	S5660_189_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	190	0		29	10	S5660_190_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	190	0		29	10	S5660_190_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	190	0		29	10	S5660_190_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	190	0		29	10	S5660_190_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	190	0		29	10	S5660_190_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	190	0		29	10	S5660_190_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	190	0		29	10	S5660_190_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	191	0		29	10	S5660_191_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	191	0		29	10	S5660_191_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	191	0		29	10	S5660_191_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	191	0		29	10	S5660_191_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	191	0		29	10	S5660_191_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	191	0		29	10	S5660_191_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	192	0		29	10	S5660_192_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	192	0		29	10	S5660_192_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	192	0		29	10	S5660_192_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	192	0		29	10	S5660_192_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	192	0		29	10	S5660_192_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	192	0		29	10	S5660_192_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	192	0		29	10	S5660_192_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	193	0		29	10	S5660_193_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	193	0		29	10	S5660_193_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	193	0		29	10	S5660_193_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	193	0		29	10	S5660_193_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	193	0		29	10	S5660_193_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
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																						2		
S5660	193	0		29	10	S5660_193_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	193	0		29	10	S5660_193_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	194	0		29	10	S5660_194_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	194	0		29	10	S5660_194_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	194	0		29	10	S5660_194_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	194	0		29	10	S5660_194_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	194	0		29	10	S5660_194_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	194	0		29	10	S5660_194_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	194	0		29	10	S5660_194_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	195	0		29	10	S5660_195_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	195	0		29	10	S5660_195_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	195	0		29	10	S5660_195_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	195	0		29	10	S5660_195_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	195	0		29	10	S5660_195_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	195	0		29	10	S5660_195_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	195	0		29	10	S5660_195_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
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																						2		
S5660	196	0		29	10	S5660_196_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	196	0		29	10	S5660_196_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	196	0		29	10	S5660_196_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	196	0		29	10	S5660_196_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	196	0		29	10	S5660_196_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	196	0		29	10	S5660_196_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	196	0		29	10	S5660_196_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	197	0		29	10	S5660_197_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	197	0		29	10	S5660_197_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	197	0		29	10	S5660_197_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	197	0		29	10	S5660_197_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	197	0		29	10	S5660_197_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	197	0		29	10	S5660_197_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	197	0		29	10	S5660_197_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	198	0		29	10	S5660_198_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	198	0		29	10	S5660_198_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	198	0		29	10	S5660_198_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	198	0		29	10	S5660_198_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	198	0		29	10	S5660_198_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	198	0		29	10	S5660_198_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	198	0		29	10	S5660_198_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	199	0		29	10	S5660_199_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	199	0		29	10	S5660_199_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	199	0		29	10	S5660_199_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	199	0		29	10	S5660_199_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	199	0		29	10	S5660_199_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	199	0		29	10	S5660_199_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	200	0		29	10	S5660_200_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		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																						2		
S5660	200	0		29	10	S5660_200_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	200	0		29	10	S5660_200_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	200	0		29	10	S5660_200_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	200	0		29	10	S5660_200_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	200	0		29	10	S5660_200_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	200	0		29	10	S5660_200_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	201	0		29	10	S5660_201_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	201	0		29	10	S5660_201_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	201	0		29	10	S5660_201_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	201	0		29	10	S5660_201_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		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																						2		
S5660	201	0		29	10	S5660_201_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	201	0		29	10	S5660_201_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	202	0		29	10	S5660_202_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	202	0		29	10	S5660_202_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	202	0		29	10	S5660_202_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	202	0		29	10	S5660_202_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	202	0		29	10	S5660_202_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	202	0		29	10	S5660_202_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	202	0		29	10	S5660_202_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	203	0		29	10	S5660_203_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	203	0		29	10	S5660_203_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	203	0		29	10	S5660_203_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5660	203	0		29	10	S5660_203_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	203	0		29	10	S5660_203_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	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	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	203	0		29	10	S5660_203_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
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																						2		
S5660	204	0		29	10	S5660_204_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	204	0		29	10	S5660_204_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	204	0		29	10	S5660_204_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	204	0		29	10	S5660_204_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	204	0		29	10	S5660_204_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5660	204	0		29	10	S5660_204_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5660	204	0		29	10	S5660_204_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	205	0		29	10	S5660_205_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5660	205	0		29	10	S5660_205_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5660	205	0		29	10	S5660_205_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5660	205	0		29	10	S5660_205_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
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																						2		
S5660	205	0		29	10	S5660_205_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5660	205	0		29	10	S5660_205_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5660	205	0		29	10	S5660_205_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
S5670	027	0		29	10	S5670_027_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	027	0		29	10	S5670_027_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	027	0		29	10	S5670_027_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	027	0		29	10	S5670_027_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	028	0		29	10	S5670_028_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	11.00	33.00								11.00			27.50								11.00			
S5670	028	0		29	10	S5670_028_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	028	0		29	10	S5670_028_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5670	028	0		29	10	S5670_028_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	030	0		29	10	S5670_030_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	030	0		29	10	S5670_030_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5670	030	0		29	10	S5670_030_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	030	0		29	10	S5670_030_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	030	0		29	10	S5670_030_0	3	5	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																						2		
S5670	030	0		29	10	S5670_030_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	030	0		29	10	S5670_030_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	030	0		29	10	S5670_030_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	030	0		29	10	S5670_030_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	030	0		29	10	S5670_030_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	033	0		29	10	S5670_033_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	033	0		29	10	S5670_033_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	033	0		29	10	S5670_033_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	033	0		29	10	S5670_033_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5670	034	0		29	10	S5670_034_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	034	0		29	10	S5670_034_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5670	034	0		29	10	S5670_034_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	034	0		29	10	S5670_034_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	036	0		29	10	S5670_036_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	036	0		29	10	S5670_036_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	036	0		29	10	S5670_036_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	036	0		29	10	S5670_036_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	036	0		29	10	S5670_036_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	036	0		29	10	S5670_036_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	036	0		29	10	S5670_036_0	3	5	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																						2		
S5670	036	0		29	10	S5670_036_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	036	0		29	10	S5670_036_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	036	0		29	10	S5670_036_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	039	0		29	10	S5670_039_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	039	0		29	10	S5670_039_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	039	0		29	10	S5670_039_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	039	0		29	10	S5670_039_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	040	0		29	10	S5670_040_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	040	0		29	10	S5670_040_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	040	0		29	10	S5670_040_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5670	040	0		29	10	S5670_040_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	042	0		29	10	S5670_042_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	042	0		29	10	S5670_042_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	042	0		29	10	S5670_042_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	042	0		29	10	S5670_042_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	042	0		29	10	S5670_042_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	042	0		29	10	S5670_042_0	3	5	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																						2		
S5670	042	0		29	10	S5670_042_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	042	0		29	10	S5670_042_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	042	0		29	10	S5670_042_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	042	0		29	10	S5670_042_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	045	0		29	10	S5670_045_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	045	0		29	10	S5670_045_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5670	045	0		29	10	S5670_045_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	045	0		29	10	S5670_045_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	046	0		29	10	S5670_046_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	046	0		29	10	S5670_046_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	046	0		29	10	S5670_046_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	51	51								51			51								51	Non-Preferred Generic and Non-Preferred Brand																								
S5670	046	0		29	10	S5670_046_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	048	0		29	10	S5670_048_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	048	0		29	10	S5670_048_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	048	0		29	10	S5670_048_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	048	0		29	10	S5670_048_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	048	0		29	10	S5670_048_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	048	0		29	10	S5670_048_0	3	5	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																						2		
S5670	048	0		29	10	S5670_048_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	048	0		29	10	S5670_048_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	048	0		29	10	S5670_048_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	048	0		29	10	S5670_048_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	051	0		29	10	S5670_051_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	051	0		29	10	S5670_051_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	051	0		29	10	S5670_051_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	051	0		29	10	S5670_051_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	052	0		29	10	S5670_052_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	052	0		29	10	S5670_052_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	052	0		29	10	S5670_052_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	51	51								51			51								51	Non-Preferred Generic and Non-Preferred Brand																								
S5670	052	0		29	10	S5670_052_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	054	0		29	10	S5670_054_0	3	5	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																						2		
S5670	054	0		29	10	S5670_054_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	054	0		29	10	S5670_054_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	054	0		29	10	S5670_054_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	054	0		29	10	S5670_054_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	054	0		29	10	S5670_054_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	054	0		29	10	S5670_054_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	054	0		29	10	S5670_054_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	054	0		29	10	S5670_054_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	054	0		29	10	S5670_054_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	057	0		29	10	S5670_057_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	057	0		29	10	S5670_057_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	63	63								63			63								63	Non-Preferred Generic and Non-Preferred Brand																								
S5670	057	0		29	10	S5670_057_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	057	0		29	10	S5670_057_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	058	0		29	10	S5670_058_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	058	0		29	10	S5670_058_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	058	0		29	10	S5670_058_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5670	058	0		29	10	S5670_058_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	060	0		29	10	S5670_060_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	060	0		29	10	S5670_060_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	060	0		29	10	S5670_060_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	060	0		29	10	S5670_060_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	060	0		29	10	S5670_060_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	060	0		29	10	S5670_060_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	060	0		29	10	S5670_060_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	060	0		29	10	S5670_060_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	060	0		29	10	S5670_060_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	060	0		29	10	S5670_060_0	3	5	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																						2		
S5670	063	0		29	10	S5670_063_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	063	0		29	10	S5670_063_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	063	0		29	10	S5670_063_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	62	62								62			62								62	Non-Preferred Generic and Non-Preferred Brand																								
S5670	063	0		29	10	S5670_063_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	064	0		29	10	S5670_064_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	064	0		29	10	S5670_064_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	49	49								49			49								49	Non-Preferred Generic and Non-Preferred Brand																								
S5670	064	0		29	10	S5670_064_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	064	0		29	10	S5670_064_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	066	0		29	10	S5670_066_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	066	0		29	10	S5670_066_0	3	5	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																						2		
S5670	066	0		29	10	S5670_066_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	066	0		29	10	S5670_066_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	066	0		29	10	S5670_066_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	066	0		29	10	S5670_066_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	066	0		29	10	S5670_066_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	066	0		29	10	S5670_066_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	066	0		29	10	S5670_066_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	066	0		29	10	S5670_066_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	069	0		29	10	S5670_069_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	069	0		29	10	S5670_069_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	069	0		29	10	S5670_069_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	63	63								63			63								63	Non-Preferred Generic and Non-Preferred Brand																								
S5670	069	0		29	10	S5670_069_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	070	0		29	10	S5670_070_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	070	0		29	10	S5670_070_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	070	0		29	10	S5670_070_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5670	070	0		29	10	S5670_070_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5670	072	0		29	10	S5670_072_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	072	0		29	10	S5670_072_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	072	0		29	10	S5670_072_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	072	0		29	10	S5670_072_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	072	0		29	10	S5670_072_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	072	0		29	10	S5670_072_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	072	0		29	10	S5670_072_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	072	0		29	10	S5670_072_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	072	0		29	10	S5670_072_0	3	5	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																						2		
S5670	072	0		29	10	S5670_072_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	075	0		29	10	S5670_075_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	075	0		29	10	S5670_075_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	075	0		29	10	S5670_075_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	075	0		29	10	S5670_075_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	076	0		29	10	S5670_076_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	54	54								54			54								54	Non-Preferred Generic and Non-Preferred Brand																								
S5670	076	0		29	10	S5670_076_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5670	076	0		29	10	S5670_076_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	076	0		29	10	S5670_076_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	078	0		29	10	S5670_078_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	078	0		29	10	S5670_078_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	078	0		29	10	S5670_078_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	078	0		29	10	S5670_078_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	078	0		29	10	S5670_078_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	078	0		29	10	S5670_078_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	078	0		29	10	S5670_078_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	078	0		29	10	S5670_078_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	078	0		29	10	S5670_078_0	3	5	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																						2		
S5670	078	0		29	10	S5670_078_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	081	0		29	10	S5670_081_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	081	0		29	10	S5670_081_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	081	0		29	10	S5670_081_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	081	0		29	10	S5670_081_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5670	082	0		29	10	S5670_082_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	082	0		29	10	S5670_082_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	56	56								56			56								56	Non-Preferred Generic and Non-Preferred Brand																								
S5670	082	0		29	10	S5670_082_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5670	082	0		29	10	S5670_082_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	084	0		29	10	S5670_084_0	3	5	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																						2		
S5670	084	0		29	10	S5670_084_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	084	0		29	10	S5670_084_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	084	0		29	10	S5670_084_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	084	0		29	10	S5670_084_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	084	0		29	10	S5670_084_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	084	0		29	10	S5670_084_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	084	0		29	10	S5670_084_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	084	0		29	10	S5670_084_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	084	0		29	10	S5670_084_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	087	0		29	10	S5670_087_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	087	0		29	10	S5670_087_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	087	0		29	10	S5670_087_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	087	0		29	10	S5670_087_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	62	62								62			62								62	Non-Preferred Generic and Non-Preferred Brand																								
S5670	088	0		29	10	S5670_088_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	088	0		29	10	S5670_088_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	088	0		29	10	S5670_088_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5670	088	0		29	10	S5670_088_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5670	090	0		29	10	S5670_090_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	090	0		29	10	S5670_090_0	3	5	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																						2		
S5670	090	0		29	10	S5670_090_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	090	0		29	10	S5670_090_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	090	0		29	10	S5670_090_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	090	0		29	10	S5670_090_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	090	0		29	10	S5670_090_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	090	0		29	10	S5670_090_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	090	0		29	10	S5670_090_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	090	0		29	10	S5670_090_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	093	0		29	10	S5670_093_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	093	0		29	10	S5670_093_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	093	0		29	10	S5670_093_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	093	0		29	10	S5670_093_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	62	62								62			62								62	Non-Preferred Generic and Non-Preferred Brand																								
S5670	094	0		29	10	S5670_094_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	094	0		29	10	S5670_094_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	094	0		29	10	S5670_094_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5670	094	0		29	10	S5670_094_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	55	55								55			55								55	Non-Preferred Generic and Non-Preferred Brand																								
S5670	096	0		29	10	S5670_096_0	3	5	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																						2		
S5670	096	0		29	10	S5670_096_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	096	0		29	10	S5670_096_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	096	0		29	10	S5670_096_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	096	0		29	10	S5670_096_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	096	0		29	10	S5670_096_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	096	0		29	10	S5670_096_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	096	0		29	10	S5670_096_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	096	0		29	10	S5670_096_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	096	0		29	10	S5670_096_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	099	0		29	10	S5670_099_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	61	61								61			61								61	Non-Preferred Generic and Non-Preferred Brand																								
S5670	099	0		29	10	S5670_099_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	099	0		29	10	S5670_099_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	099	0		29	10	S5670_099_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	100	0		29	10	S5670_100_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	100	0		29	10	S5670_100_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	100	0		29	10	S5670_100_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5670	100	0		29	10	S5670_100_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	102	0		29	10	S5670_102_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	102	0		29	10	S5670_102_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	102	0		29	10	S5670_102_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	102	0		29	10	S5670_102_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	102	0		29	10	S5670_102_0	3	5	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																						2		
S5670	102	0		29	10	S5670_102_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	102	0		29	10	S5670_102_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	102	0		29	10	S5670_102_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	102	0		29	10	S5670_102_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	102	0		29	10	S5670_102_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	105	0		29	10	S5670_105_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	105	0		29	10	S5670_105_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	105	0		29	10	S5670_105_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	105	0		29	10	S5670_105_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	106	0		29	10	S5670_106_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	106	0		29	10	S5670_106_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5670	106	0		29	10	S5670_106_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	106	0		29	10	S5670_106_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	108	0		29	10	S5670_108_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	108	0		29	10	S5670_108_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	108	0		29	10	S5670_108_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	108	0		29	10	S5670_108_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	108	0		29	10	S5670_108_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	108	0		29	10	S5670_108_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	108	0		29	10	S5670_108_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	108	0		29	10	S5670_108_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	108	0		29	10	S5670_108_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	108	0		29	10	S5670_108_0	3	5	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																						2		
S5670	111	0		29	10	S5670_111_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	111	0		29	10	S5670_111_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	62	62								62			62								62	Non-Preferred Generic and Non-Preferred Brand																								
S5670	111	0		29	10	S5670_111_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	111	0		29	10	S5670_111_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	112	0		29	10	S5670_112_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	112	0		29	10	S5670_112_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	112	0		29	10	S5670_112_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	50	50								50			50								50	Non-Preferred Generic and Non-Preferred Brand																								
S5670	112	0		29	10	S5670_112_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	114	0		29	10	S5670_114_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	114	0		29	10	S5670_114_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	114	0		29	10	S5670_114_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	114	0		29	10	S5670_114_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	114	0		29	10	S5670_114_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	114	0		29	10	S5670_114_0	3	5	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																						2		
S5670	114	0		29	10	S5670_114_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	114	0		29	10	S5670_114_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	114	0		29	10	S5670_114_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	114	0		29	10	S5670_114_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	117	0		29	10	S5670_117_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	117	0		29	10	S5670_117_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	117	0		29	10	S5670_117_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	117	0		29	10	S5670_117_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	118	0		29	10	S5670_118_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5670	118	0		29	10	S5670_118_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	118	0		29	10	S5670_118_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	118	0		29	10	S5670_118_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	120	0		29	10	S5670_120_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	120	0		29	10	S5670_120_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	120	0		29	10	S5670_120_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	120	0		29	10	S5670_120_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	120	0		29	10	S5670_120_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	120	0		29	10	S5670_120_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	120	0		29	10	S5670_120_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	120	0		29	10	S5670_120_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	120	0		29	10	S5670_120_0	3	5	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																						2		
S5670	120	0		29	10	S5670_120_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	123	0		29	10	S5670_123_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	123	0		29	10	S5670_123_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5670	123	0		29	10	S5670_123_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	123	0		29	10	S5670_123_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	124	0		29	10	S5670_124_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	124	0		29	10	S5670_124_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	50	50								50			50								50	Non-Preferred Generic and Non-Preferred Brand																								
S5670	124	0		29	10	S5670_124_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	124	0		29	10	S5670_124_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	126	0		29	10	S5670_126_0	3	5	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																						2		
S5670	126	0		29	10	S5670_126_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	126	0		29	10	S5670_126_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	126	0		29	10	S5670_126_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	126	0		29	10	S5670_126_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	126	0		29	10	S5670_126_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	126	0		29	10	S5670_126_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	126	0		29	10	S5670_126_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	126	0		29	10	S5670_126_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	126	0		29	10	S5670_126_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	129	0		29	10	S5670_129_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	129	0		29	10	S5670_129_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	129	0		29	10	S5670_129_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	129	0		29	10	S5670_129_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	130	0		29	10	S5670_130_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	11.00	33.00								11.00			27.50								11.00			
S5670	130	0		29	10	S5670_130_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5670	130	0		29	10	S5670_130_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5670	130	0		29	10	S5670_130_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	132	0		29	10	S5670_132_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	132	0		29	10	S5670_132_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	1	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	132	0		29	10	S5670_132_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5670	132	0		29	10	S5670_132_0	3	5	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																						2		
S5670	132	0		29	10	S5670_132_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	132	0		29	10	S5670_132_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	132	0		29	10	S5670_132_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	132	0		29	10	S5670_132_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	132	0		29	10	S5670_132_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	132	0		29	10	S5670_132_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	135	0		29	10	S5670_135_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	135	0		29	10	S5670_135_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5670	135	0		29	10	S5670_135_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5670	135	0		29	10	S5670_135_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	136	0		29	10	S5670_136_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	136	0		29	10	S5670_136_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	56	56								56			56								56	Non-Preferred Generic and Non-Preferred Brand																								
S5670	136	0		29	10	S5670_136_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5670	136	0		29	10	S5670_136_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	138	0		29	10	S5670_138_0	3	5	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																						2		
S5670	138	0		29	10	S5670_138_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	138	0		29	10	S5670_138_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	138	0		29	10	S5670_138_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	138	0		29	10	S5670_138_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	138	0		29	10	S5670_138_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	138	0		29	10	S5670_138_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	138	0		29	10	S5670_138_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	138	0		29	10	S5670_138_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	138	0		29	10	S5670_138_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	141	0		29	10	S5670_141_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	141	0		29	10	S5670_141_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	141	0		29	10	S5670_141_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	141	0		29	10	S5670_141_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	62	62								62			62								62	Non-Preferred Generic and Non-Preferred Brand																								
S5670	142	0		29	10	S5670_142_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	14	14								14			13								14	Preferred Brand																								
S5670	142	0		29	10	S5670_142_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	60	60								60			60								60	Non-Preferred Generic and Non-Preferred Brand																								
S5670	142	0		29	10	S5670_142_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	142	0		29	10	S5670_142_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	14.00	42.00								14.00			35.00								14.00			
S5670	144	0		29	10	S5670_144_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	144	0		29	10	S5670_144_0	3	5	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																						2		
S5670	144	0		29	10	S5670_144_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	144	0		29	10	S5670_144_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	144	0		29	10	S5670_144_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	144	0		29	10	S5670_144_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	144	0		29	10	S5670_144_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	144	0		29	10	S5670_144_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	144	0		29	10	S5670_144_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	144	0		29	10	S5670_144_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	147	0		29	10	S5670_147_0	3	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5670	147	0		29	10	S5670_147_0	3	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5670	147	0		29	10	S5670_147_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	147	0		29	10	S5670_147_0	3	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5670	148	0		29	10	S5670_148_0	3	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5670	148	0		29	10	S5670_148_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5670	148	0		29	10	S5670_148_0	3	3	3	1	Non-Preferred Generic and Non-Preferred Brand	100100		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	56	56								56			56								56	Non-Preferred Generic and Non-Preferred Brand																								
S5670	148	0		29	10	S5670_148_0	3	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5670	150	0		29	10	S5670_150_0	3	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5670	150	0		29	10	S5670_150_0	3	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5670	150	0		29	10	S5670_150_0	3	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5670	150	0		29	10	S5670_150_0	3	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5670	150	0		29	10	S5670_150_0	3	5	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																						2		
S5670	150	0		29	10	S5670_150_0	3	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5670	150	0		29	10	S5670_150_0	3	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5670	150	0		29	10	S5670_150_0	3	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5670	150	0		29	10	S5670_150_0	3	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5670	150	0		29	10	S5670_150_0	3	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	002	0		29	10	S5674_002_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	62	62								62			62								62	Non-Preferred Generic and Non-Preferred Brand																								
S5674	002	0		29	10	S5674_002_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	002	0		29	10	S5674_002_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	002	0		29	10	S5674_002_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	003	0		29	10	S5674_003_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	56	56								56			56								56	Non-Preferred Generic and Non-Preferred Brand																								
S5674	003	0		29	10	S5674_003_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5674	003	0		29	10	S5674_003_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	003	0		29	10	S5674_003_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	005	0		29	10	S5674_005_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	005	0		29	10	S5674_005_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	005	0		29	10	S5674_005_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	005	0		29	10	S5674_005_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	005	0		29	10	S5674_005_0	2	5	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																						2		
S5674	005	0		29	10	S5674_005_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	005	0		29	10	S5674_005_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	005	0		29	10	S5674_005_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	005	0		29	10	S5674_005_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	005	0		29	10	S5674_005_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	008	0		29	10	S5674_008_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5674	008	0		29	10	S5674_008_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	008	0		29	10	S5674_008_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	008	0		29	10	S5674_008_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	009	0		29	10	S5674_009_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	009	0		29	10	S5674_009_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	51	51								51			51								51	Non-Preferred Generic and Non-Preferred Brand																								
S5674	009	0		29	10	S5674_009_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	009	0		29	10	S5674_009_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5674	011	0		29	10	S5674_011_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	011	0		29	10	S5674_011_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	011	0		29	10	S5674_011_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	011	0		29	10	S5674_011_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	011	0		29	10	S5674_011_0	2	5	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																						2		
S5674	011	0		29	10	S5674_011_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	011	0		29	10	S5674_011_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	011	0		29	10	S5674_011_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	011	0		29	10	S5674_011_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	011	0		29	10	S5674_011_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	014	0		29	10	S5674_014_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	014	0		29	10	S5674_014_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	014	0		29	10	S5674_014_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5674	014	0		29	10	S5674_014_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5674	015	0		29	10	S5674_015_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5674	015	0		29	10	S5674_015_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	015	0		29	10	S5674_015_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00			
S5674	015	0		29	10	S5674_015_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5674	017	0		29	10	S5674_017_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5674	017	0		29	10	S5674_017_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	017	0		29	10	S5674_017_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5674	017	0		29	10	S5674_017_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	017	0		29	10	S5674_017_0	2	5	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																						2		
S5674	017	0		29	10	S5674_017_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	017	0		29	10	S5674_017_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	017	0		29	10	S5674_017_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	017	0		29	10	S5674_017_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	017	0		29	10	S5674_017_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	020	0		29	10	S5674_020_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	020	0		29	10	S5674_020_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	66	66								66			66								66	Non-Preferred Generic and Non-Preferred Brand																								
S5674	020	0		29	10	S5674_020_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	020	0		29	10	S5674_020_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	021	0		29	10	S5674_021_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	55	55								55			55								55	Non-Preferred Generic and Non-Preferred Brand																								
S5674	021	0		29	10	S5674_021_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5674	021	0		29	10	S5674_021_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	021	0		29	10	S5674_021_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	023	0		29	10	S5674_023_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	023	0		29	10	S5674_023_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	023	0		29	10	S5674_023_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	023	0		29	10	S5674_023_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	023	0		29	10	S5674_023_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	023	0		29	10	S5674_023_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	023	0		29	10	S5674_023_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	023	0		29	10	S5674_023_0	2	5	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																						2		
S5674	023	0		29	10	S5674_023_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	023	0		29	10	S5674_023_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	026	0		29	10	S5674_026_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	026	0		29	10	S5674_026_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	026	0		29	10	S5674_026_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5674	026	0		29	10	S5674_026_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	027	0		29	10	S5674_027_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	11.00	33.00								11.00			27.50								11.00			
S5674	027	0		29	10	S5674_027_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5674	027	0		29	10	S5674_027_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	54	54								54			54								54	Non-Preferred Generic and Non-Preferred Brand																								
S5674	027	0		29	10	S5674_027_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	029	0		29	10	S5674_029_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	029	0		29	10	S5674_029_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	029	0		29	10	S5674_029_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	029	0		29	10	S5674_029_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	029	0		29	10	S5674_029_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	029	0		29	10	S5674_029_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	029	0		29	10	S5674_029_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	029	0		29	10	S5674_029_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	029	0		29	10	S5674_029_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	029	0		29	10	S5674_029_0	2	5	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																						2		
S5674	032	0		29	10	S5674_032_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	032	0		29	10	S5674_032_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	032	0		29	10	S5674_032_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	61	61								61			61								61	Non-Preferred Generic and Non-Preferred Brand																								
S5674	032	0		29	10	S5674_032_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	033	0		29	10	S5674_033_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	11.00	33.00								11.00			27.50								11.00			
S5674	033	0		29	10	S5674_033_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	033	0		29	10	S5674_033_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	51	51								51			51								51	Non-Preferred Generic and Non-Preferred Brand																								
S5674	033	0		29	10	S5674_033_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	035	0		29	10	S5674_035_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	035	0		29	10	S5674_035_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	035	0		29	10	S5674_035_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	035	0		29	10	S5674_035_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	035	0		29	10	S5674_035_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	035	0		29	10	S5674_035_0	2	5	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																						2		
S5674	035	0		29	10	S5674_035_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	035	0		29	10	S5674_035_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5674	035	0		29	10	S5674_035_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	035	0		29	10	S5674_035_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	038	0		29	10	S5674_038_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	038	0		29	10	S5674_038_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	67	67								67			67								67	Non-Preferred Generic and Non-Preferred Brand																								
S5674	038	0		29	10	S5674_038_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	038	0		29	10	S5674_038_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	039	0		29	10	S5674_039_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	039	0		29	10	S5674_039_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	039	0		29	10	S5674_039_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	55	55								55			55								55	Non-Preferred Generic and Non-Preferred Brand																								
S5674	039	0		29	10	S5674_039_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	041	0		29	10	S5674_041_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	041	0		29	10	S5674_041_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	041	0		29	10	S5674_041_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	041	0		29	10	S5674_041_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	041	0		29	10	S5674_041_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	041	0		29	10	S5674_041_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	041	0		29	10	S5674_041_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	041	0		29	10	S5674_041_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	041	0		29	10	S5674_041_0	2	5	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																						2		
S5674	041	0		29	10	S5674_041_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	044	0		29	10	S5674_044_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	65	65								65			65								65	Non-Preferred Generic and Non-Preferred Brand																								
S5674	044	0		29	10	S5674_044_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	044	0		29	10	S5674_044_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	044	0		29	10	S5674_044_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	045	0		29	10	S5674_045_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5674	045	0		29	10	S5674_045_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	045	0		29	10	S5674_045_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	045	0		29	10	S5674_045_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5674	047	0		29	10	S5674_047_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	047	0		29	10	S5674_047_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	047	0		29	10	S5674_047_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	047	0		29	10	S5674_047_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5674	047	0		29	10	S5674_047_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	047	0		29	10	S5674_047_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	047	0		29	10	S5674_047_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	047	0		29	10	S5674_047_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	047	0		29	10	S5674_047_0	2	5	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																						2		
S5674	047	0		29	10	S5674_047_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	050	0		29	10	S5674_050_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	050	0		29	10	S5674_050_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	050	0		29	10	S5674_050_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5674	050	0		29	10	S5674_050_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	051	0		29	10	S5674_051_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	051	0		29	10	S5674_051_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	54	54								54			54								54	Non-Preferred Generic and Non-Preferred Brand																								
S5674	051	0		29	10	S5674_051_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5674	051	0		29	10	S5674_051_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	053	0		29	10	S5674_053_0	2	5	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																						2		
S5674	053	0		29	10	S5674_053_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	053	0		29	10	S5674_053_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	053	0		29	10	S5674_053_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	053	0		29	10	S5674_053_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	053	0		29	10	S5674_053_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	053	0		29	10	S5674_053_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	053	0		29	10	S5674_053_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	053	0		29	10	S5674_053_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	053	0		29	10	S5674_053_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	056	0		29	10	S5674_056_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5674	056	0		29	10	S5674_056_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	056	0		29	10	S5674_056_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	64	64								64			64								64	Non-Preferred Generic and Non-Preferred Brand																								
S5674	056	0		29	10	S5674_056_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	057	0		29	10	S5674_057_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	057	0		29	10	S5674_057_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	17	17								17			16								17	Preferred Brand																								
S5674	057	0		29	10	S5674_057_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	55	55								55			55								55	Non-Preferred Generic and Non-Preferred Brand																								
S5674	057	0		29	10	S5674_057_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	059	0		29	10	S5674_059_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	059	0		29	10	S5674_059_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	059	0		29	10	S5674_059_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	19	19								19			17								19	Preferred Brand																								
S5674	059	0		29	10	S5674_059_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	059	0		29	10	S5674_059_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	059	0		29	10	S5674_059_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	059	0		29	10	S5674_059_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	059	0		29	10	S5674_059_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	059	0		29	10	S5674_059_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	059	0		29	10	S5674_059_0	2	5	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																						2		
S5674	062	0		29	10	S5674_062_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	61	61								61			61								61	Non-Preferred Generic and Non-Preferred Brand																								
S5674	062	0		29	10	S5674_062_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	062	0		29	10	S5674_062_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	062	0		29	10	S5674_062_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			17.50								7.00			
S5674	063	0		29	10	S5674_063_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	063	0		29	10	S5674_063_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	60	60								60			60								60	Non-Preferred Generic and Non-Preferred Brand																								
S5674	063	0		29	10	S5674_063_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	18	18								18			16								18	Preferred Brand																								
S5674	063	0		29	10	S5674_063_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	065	0		29	10	S5674_065_0	2	5	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																						2		
S5674	065	0		29	10	S5674_065_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	065	0		29	10	S5674_065_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	065	0		29	10	S5674_065_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	065	0		29	10	S5674_065_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	065	0		29	10	S5674_065_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	065	0		29	10	S5674_065_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5674	065	0		29	10	S5674_065_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	065	0		29	10	S5674_065_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	065	0		29	10	S5674_065_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	068	0		29	10	S5674_068_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00								6.00			15.00								6.00			
S5674	068	0		29	10	S5674_068_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	068	0		29	10	S5674_068_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	66	66								66			66								66	Non-Preferred Generic and Non-Preferred Brand																								
S5674	068	0		29	10	S5674_068_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	30									30											30	Specialty - Generic and Brand																								
S5674	069	0		29	10	S5674_069_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	12.00	36.00								12.00			30.00								12.00			
S5674	069	0		29	10	S5674_069_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	16	16								16			15								16	Preferred Brand																								
S5674	069	0		29	10	S5674_069_0	2	3	3	1	Non-Preferred Generic and Non-Preferred Brand	000101		2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5674	069	0		29	10	S5674_069_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	071	0		29	10	S5674_071_0	2	1	4	1	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	5.00	15.00								5.00			12.50								5.00			
S5674	071	0		29	10	S5674_071_0	2	5	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																						2		
S5674	071	0		29	10	S5674_071_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5674	071	0		29	10	S5674_071_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5674	071	0		29	10	S5674_071_0	2	2	4	3	Generics	010000	1	2	2	Generics																								Generics		Generics																						Generics																						2		
S5674	071	0		29	10	S5674_071_0	2	1	4	3	Preferred Generic	001000	3	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	15.00	45.00								15.00			37.50								15.00	1	1	
S5674	071	0		29	10	S5674_071_0	2	5	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	33									33											33	Specialty - Generic and Brand																								
S5674	071	0		29	10	S5674_071_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010010000000	30	90								30			90								31	2	Generics	2	Generics																						Generics	25.00	75.00								25.00			62.50								25.00			
S5674	071	0		29	10	S5674_071_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5674	071	0		29	10	S5674_071_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75			75								75	Non-Preferred Brand																								
S5678	001	0		29	10	S5678_001_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	001	0		29	10	S5678_001_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	36.00	108.00	72.00							36.00					36.00	72.00	72.00	36.00	108.00	72.00	36.00			
S5678	001	0		29	10	S5678_001_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	001	0		29	10	S5678_001_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	001	0		29	10	S5678_001_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	002	0		29	10	S5678_002_0	2	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	002	0		29	10	S5678_002_0	2	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	002	0		29	10	S5678_002_0	2	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	33.00	99.00	66.00							33.00					33.00	66.00	66.00	33.00	99.00	66.00	33.00			
S5678	002	0		29	10	S5678_002_0	2	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	002	0		29	10	S5678_002_0	2	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	003	0		29	10	S5678_003_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	003	0		29	10	S5678_003_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	003	0		29	10	S5678_003_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	003	0		29	10	S5678_003_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	003	0		29	10	S5678_003_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	004	0		29	10	S5678_004_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	004	0		29	10	S5678_004_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	004	0		29	10	S5678_004_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	004	0		29	10	S5678_004_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	004	0		29	10	S5678_004_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	005	0		29	10	S5678_005_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	005	0		29	10	S5678_005_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	005	0		29	10	S5678_005_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	005	0		29	10	S5678_005_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	005	0		29	10	S5678_005_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	006	0		29	10	S5678_006_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.00	117.00	78.00							39.00					39.00	78.00	78.00	39.00	117.00	78.00	39.00			
S5678	006	0		29	10	S5678_006_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	006	0		29	10	S5678_006_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	006	0		29	10	S5678_006_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	006	0		29	10	S5678_006_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	007	0		29	10	S5678_007_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	007	0		29	10	S5678_007_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	007	0		29	10	S5678_007_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	007	0		29	10	S5678_007_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	007	0		29	10	S5678_007_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	008	0		29	10	S5678_008_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	008	0		29	10	S5678_008_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	008	0		29	10	S5678_008_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	008	0		29	10	S5678_008_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	008	0		29	10	S5678_008_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	009	0		29	10	S5678_009_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	009	0		29	10	S5678_009_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	009	0		29	10	S5678_009_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	009	0		29	10	S5678_009_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	009	0		29	10	S5678_009_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	010	0		29	10	S5678_010_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	010	0		29	10	S5678_010_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	010	0		29	10	S5678_010_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	010	0		29	10	S5678_010_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	010	0		29	10	S5678_010_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	011	0		29	10	S5678_011_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	011	0		29	10	S5678_011_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	011	0		29	10	S5678_011_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	011	0		29	10	S5678_011_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	011	0		29	10	S5678_011_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	012	0		29	10	S5678_012_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	012	0		29	10	S5678_012_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	012	0		29	10	S5678_012_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	012	0		29	10	S5678_012_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	012	0		29	10	S5678_012_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	013	0		29	10	S5678_013_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	013	0		29	10	S5678_013_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	013	0		29	10	S5678_013_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	013	0		29	10	S5678_013_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	013	0		29	10	S5678_013_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	014	0		29	10	S5678_014_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	014	0		29	10	S5678_014_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	014	0		29	10	S5678_014_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	014	0		29	10	S5678_014_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	014	0		29	10	S5678_014_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00	82.00							41.00					41.00	82.00	82.00	41.00	123.00	82.00	41.00			
S5678	015	0		29	10	S5678_015_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	015	0		29	10	S5678_015_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	015	0		29	10	S5678_015_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	015	0		29	10	S5678_015_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	015	0		29	10	S5678_015_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	016	0		29	10	S5678_016_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	016	0		29	10	S5678_016_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00	82.00							41.00					41.00	82.00	82.00	41.00	123.00	82.00	41.00			
S5678	016	0		29	10	S5678_016_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	016	0		29	10	S5678_016_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	016	0		29	10	S5678_016_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	017	0		29	10	S5678_017_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	017	0		29	10	S5678_017_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	017	0		29	10	S5678_017_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	017	0		29	10	S5678_017_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	017	0		29	10	S5678_017_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	018	0		29	10	S5678_018_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.00	117.00	78.00							39.00					39.00	78.00	78.00	39.00	117.00	78.00	39.00			
S5678	018	0		29	10	S5678_018_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	018	0		29	10	S5678_018_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	018	0		29	10	S5678_018_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	018	0		29	10	S5678_018_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	019	0		29	10	S5678_019_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	019	0		29	10	S5678_019_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	019	0		29	10	S5678_019_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	019	0		29	10	S5678_019_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	019	0		29	10	S5678_019_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	020	0		29	10	S5678_020_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	020	0		29	10	S5678_020_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	020	0		29	10	S5678_020_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	37.00	111.00	74.00							37.00					37.00	74.00	74.00	37.00	111.00	74.00	37.00			
S5678	020	0		29	10	S5678_020_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	020	0		29	10	S5678_020_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	021	0		29	10	S5678_021_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	021	0		29	10	S5678_021_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	021	0		29	10	S5678_021_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	021	0		29	10	S5678_021_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	021	0		29	10	S5678_021_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	022	0		29	10	S5678_022_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	022	0		29	10	S5678_022_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	022	0		29	10	S5678_022_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	022	0		29	10	S5678_022_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	022	0		29	10	S5678_022_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	023	0		29	10	S5678_023_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	023	0		29	10	S5678_023_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	023	0		29	10	S5678_023_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	023	0		29	10	S5678_023_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	023	0		29	10	S5678_023_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	024	0		29	10	S5678_024_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	024	0		29	10	S5678_024_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	024	0		29	10	S5678_024_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	024	0		29	10	S5678_024_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	024	0		29	10	S5678_024_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	025	0		29	10	S5678_025_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	025	0		29	10	S5678_025_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	025	0		29	10	S5678_025_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	025	0		29	10	S5678_025_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	025	0		29	10	S5678_025_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	026	0		29	10	S5678_026_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	37.00	111.00	74.00							37.00					37.00	74.00	74.00	37.00	111.00	74.00	37.00			
S5678	026	0		29	10	S5678_026_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	026	0		29	10	S5678_026_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	026	0		29	10	S5678_026_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	026	0		29	10	S5678_026_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	027	0		29	10	S5678_027_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	027	0		29	10	S5678_027_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	027	0		29	10	S5678_027_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	027	0		29	10	S5678_027_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	027	0		29	10	S5678_027_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	028	0		29	10	S5678_028_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	37.00	111.00	74.00							37.00					37.00	74.00	74.00	37.00	111.00	74.00	37.00			
S5678	028	0		29	10	S5678_028_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	028	0		29	10	S5678_028_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	028	0		29	10	S5678_028_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	028	0		29	10	S5678_028_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	029	0		29	10	S5678_029_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	029	0		29	10	S5678_029_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	029	0		29	10	S5678_029_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	029	0		29	10	S5678_029_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	029	0		29	10	S5678_029_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	030	0		29	10	S5678_030_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	030	0		29	10	S5678_030_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	030	0		29	10	S5678_030_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	030	0		29	10	S5678_030_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	030	0		29	10	S5678_030_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	031	0		29	10	S5678_031_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	031	0		29	10	S5678_031_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	031	0		29	10	S5678_031_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	031	0		29	10	S5678_031_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	031	0		29	10	S5678_031_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	032	0		29	10	S5678_032_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	032	0		29	10	S5678_032_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	032	0		29	10	S5678_032_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	40.00	120.00	80.00							40.00					40.00	80.00	80.00	40.00	120.00	80.00	40.00			
S5678	032	0		29	10	S5678_032_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	032	0		29	10	S5678_032_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	033	0		29	10	S5678_033_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	033	0		29	10	S5678_033_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	033	0		29	10	S5678_033_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	033	0		29	10	S5678_033_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	033	0		29	10	S5678_033_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	034	0		29	10	S5678_034_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	034	0		29	10	S5678_034_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	034	0		29	10	S5678_034_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	034	0		29	10	S5678_034_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.00	117.00	78.00							39.00					39.00	78.00	78.00	39.00	117.00	78.00	39.00			
S5678	034	0		29	10	S5678_034_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	035	0		29	10	S5678_035_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	035	0		29	10	S5678_035_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	035	0		29	10	S5678_035_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	035	0		29	10	S5678_035_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	035	0		29	10	S5678_035_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	036	0		29	10	S5678_036_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	036	0		29	10	S5678_036_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	036	0		29	10	S5678_036_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	036	0		29	10	S5678_036_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	036	0		29	10	S5678_036_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	037	0		29	10	S5678_037_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	037	0		29	10	S5678_037_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	037	0		29	10	S5678_037_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	037	0		29	10	S5678_037_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	037	0		29	10	S5678_037_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	038	0		29	10	S5678_038_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	038	0		29	10	S5678_038_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	41.00	123.00	82.00							41.00					41.00	82.00	82.00	41.00	123.00	82.00	41.00			
S5678	038	0		29	10	S5678_038_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	038	0		29	10	S5678_038_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	038	0		29	10	S5678_038_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	039	0		29	10	S5678_039_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	039	0		29	10	S5678_039_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	039	0		29	10	S5678_039_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	039	0		29	10	S5678_039_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	039	0		29	10	S5678_039_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	040	0		29	10	S5678_040_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	040	0		29	10	S5678_040_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	040	0		29	10	S5678_040_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	040	0		29	10	S5678_040_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	040	0		29	10	S5678_040_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	041	0		29	10	S5678_041_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	041	0		29	10	S5678_041_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	041	0		29	10	S5678_041_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	041	0		29	10	S5678_041_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	041	0		29	10	S5678_041_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	042	0		29	10	S5678_042_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	042	0		29	10	S5678_042_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	37.00	111.00	74.00							37.00					37.00	74.00	74.00	37.00	111.00	74.00	37.00			
S5678	042	0		29	10	S5678_042_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	042	0		29	10	S5678_042_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	042	0		29	10	S5678_042_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	043	0		29	10	S5678_043_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	043	0		29	10	S5678_043_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	043	0		29	10	S5678_043_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	043	0		29	10	S5678_043_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	043	0		29	10	S5678_043_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	044	0		29	10	S5678_044_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	044	0		29	10	S5678_044_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	044	0		29	10	S5678_044_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5678	044	0		29	10	S5678_044_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	044	0		29	10	S5678_044_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	045	0		29	10	S5678_045_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	045	0		29	10	S5678_045_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	045	0		29	10	S5678_045_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	045	0		29	10	S5678_045_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	045	0		29	10	S5678_045_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	046	0		29	10	S5678_046_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	046	0		29	10	S5678_046_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	37.00	111.00	74.00							37.00					37.00	74.00	74.00	37.00	111.00	74.00	37.00			
S5678	046	0		29	10	S5678_046_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	046	0		29	10	S5678_046_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	046	0		29	10	S5678_046_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	047	0		29	10	S5678_047_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	047	0		29	10	S5678_047_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	047	0		29	10	S5678_047_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	047	0		29	10	S5678_047_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	047	0		29	10	S5678_047_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	048	0		29	10	S5678_048_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	048	0		29	10	S5678_048_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	048	0		29	10	S5678_048_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	36.00	108.00	72.00							36.00					36.00	72.00	72.00	36.00	108.00	72.00	36.00			
S5678	048	0		29	10	S5678_048_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	048	0		29	10	S5678_048_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	049	0		29	10	S5678_049_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	049	0		29	10	S5678_049_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	049	0		29	10	S5678_049_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	049	0		29	10	S5678_049_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	049	0		29	10	S5678_049_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	050	0		29	10	S5678_050_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	050	0		29	10	S5678_050_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	36.00	108.00	72.00							36.00					36.00	72.00	72.00	36.00	108.00	72.00	36.00			
S5678	050	0		29	10	S5678_050_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	050	0		29	10	S5678_050_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	050	0		29	10	S5678_050_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	051	0		29	10	S5678_051_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	051	0		29	10	S5678_051_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	051	0		29	10	S5678_051_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	051	0		29	10	S5678_051_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	051	0		29	10	S5678_051_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	052	0		29	10	S5678_052_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	052	0		29	10	S5678_052_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	052	0		29	10	S5678_052_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	052	0		29	10	S5678_052_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.00	117.00	78.00							39.00					39.00	78.00	78.00	39.00	117.00	78.00	39.00			
S5678	052	0		29	10	S5678_052_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	053	0		29	10	S5678_053_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	053	0		29	10	S5678_053_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	053	0		29	10	S5678_053_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	053	0		29	10	S5678_053_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	053	0		29	10	S5678_053_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	054	0		29	10	S5678_054_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	054	0		29	10	S5678_054_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	054	0		29	10	S5678_054_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	054	0		29	10	S5678_054_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	054	0		29	10	S5678_054_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.00	117.00	78.00							39.00					39.00	78.00	78.00	39.00	117.00	78.00	39.00			
S5678	055	0		29	10	S5678_055_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	055	0		29	10	S5678_055_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	055	0		29	10	S5678_055_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	055	0		29	10	S5678_055_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	055	0		29	10	S5678_055_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	056	0		29	10	S5678_056_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	056	0		29	10	S5678_056_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	056	0		29	10	S5678_056_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	40.00	120.00	80.00							40.00					40.00	80.00	80.00	40.00	120.00	80.00	40.00			
S5678	056	0		29	10	S5678_056_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	056	0		29	10	S5678_056_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	057	0		29	10	S5678_057_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	057	0		29	10	S5678_057_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	057	0		29	10	S5678_057_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	057	0		29	10	S5678_057_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	057	0		29	10	S5678_057_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	058	0		29	10	S5678_058_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	058	0		29	10	S5678_058_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	058	0		29	10	S5678_058_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	058	0		29	10	S5678_058_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	36.00	108.00	72.00							36.00					36.00	72.00	72.00	36.00	108.00	72.00	36.00			
S5678	058	0		29	10	S5678_058_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	059	0		29	10	S5678_059_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	059	0		29	10	S5678_059_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	059	0		29	10	S5678_059_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	059	0		29	10	S5678_059_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	059	0		29	10	S5678_059_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	060	0		29	10	S5678_060_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	060	0		29	10	S5678_060_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	060	0		29	10	S5678_060_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	060	0		29	10	S5678_060_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	060	0		29	10	S5678_060_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	39.00	117.00	78.00							39.00					39.00	78.00	78.00	39.00	117.00	78.00	39.00			
S5678	061	0		29	10	S5678_061_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	061	0		29	10	S5678_061_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	061	0		29	10	S5678_061_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	061	0		29	10	S5678_061_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	061	0		29	10	S5678_061_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	062	0		29	10	S5678_062_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	062	0		29	10	S5678_062_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	062	0		29	10	S5678_062_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	36.00	108.00	72.00							36.00					36.00	72.00	72.00	36.00	108.00	72.00	36.00			
S5678	062	0		29	10	S5678_062_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	062	0		29	10	S5678_062_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	063	0		29	10	S5678_063_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	063	0		29	10	S5678_063_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	063	0		29	10	S5678_063_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	063	0		29	10	S5678_063_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	063	0		29	10	S5678_063_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	064	0		29	10	S5678_064_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	064	0		29	10	S5678_064_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	064	0		29	10	S5678_064_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	064	0		29	10	S5678_064_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	064	0		29	10	S5678_064_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	065	0		29	10	S5678_065_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	065	0		29	10	S5678_065_0	1	3	4	1	Tier 3 Non- Preferred	100100	1	2	1	Tier 3 Non- Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non- Preferred	2	Tier 3 Non- Preferred																						Tier 3 Non- Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	065	0		29	10	S5678_065_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	35.00	105.00	70.00							35.00					35.00	70.00	70.00	35.00	105.00	70.00	35.00			
S5678	065	0		29	10	S5678_065_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	5.00	15.00	10.00							5.00					5.00	10.00	10.00	5.00	15.00	10.00	5.00			
S5678	065	0		29	10	S5678_065_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	066	0		29	10	S5678_066_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	066	0		29	10	S5678_066_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	066	0		29	10	S5678_066_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	066	0		29	10	S5678_066_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	066	0		29	10	S5678_066_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	067	0		29	10	S5678_067_0	1	2	4	1	Tier 2 Preferred Brand	000101	1	2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	42.00	126.00	84.00							42.00					42.00	84.00	84.00	42.00	126.00	84.00	42.00			
S5678	067	0		29	10	S5678_067_0	1	4	4	1	Tier 4 Injectable	010010	1	2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	33									33											33	Tier 4 Injectable																								
S5678	067	0		29	10	S5678_067_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	33									33											33	Tier 5 Specialty																								
S5678	067	0		29	10	S5678_067_0	1	3	4	1	Tier 3 Non-Preferred	100100	1	2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	067	0		29	10	S5678_067_0	1	1	4	1	Tier 1 Preferred Generic	001001	1	2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	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	0.00	0.00	0.00			
S5678	068	0		29	10	S5678_068_0	1	1	2	1	Tier 1 Preferred Generic	001001		2	2	Tier 1 Preferred Generic	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00	8.00							4.00					4.00	8.00	8.00	4.00	12.00	8.00	4.00			
S5678	068	0		29	10	S5678_068_0	1	5	2	1	Tier 5 Specialty	010010		1	2	Tier 5 Specialty	110000000010000000000	30									30											34		Tier 5 Specialty	1	Tier 5 Specialty	25									25											25	Tier 5 Specialty																								
S5678	068	0		29	10	S5678_068_0	1	4	2	1	Tier 4 Injectable	010010		2	2	Tier 4 Injectable	110000000010000000000	30									30											34		Tier 4 Injectable	1	Tier 4 Injectable	25									25											25	Tier 4 Injectable																								
S5678	068	0		29	10	S5678_068_0	1	3	2	1	Tier 3 Non-Preferred	100100		2	1	Tier 3 Non-Preferred	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 3 Non-Preferred	2	Tier 3 Non-Preferred																						Tier 3 Non-Preferred	95.00	285.00	190.00							95.00					95.00	238.00	190.00	95.00	285.00	190.00	95.00			
S5678	068	0		29	10	S5678_068_0	1	2	2	1	Tier 2 Preferred Brand	000101		2	2	Tier 2 Preferred Brand	111100000010000111111	30	90	60							30					30	90	60	30	90	60	34	1	Tier 2 Preferred Brand	2	Tier 2 Preferred Brand																						Tier 2 Preferred Brand	38.00	114.00	76.00							38.00					38.00	76.00	76.00	38.00	114.00	76.00	38.00			
S5715	001	0		29	10	S5715_001_0	5	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				11.00	27.50		11.00	33.00		11.00			27.50								11.00			
S5715	001	0		29	10	S5715_001_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				45.00	112.50		45.00	135.00		45.00			112.50								45.00			
S5715	001	0		29	10	S5715_001_0	5	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5715	001	0		29	10	S5715_001_0	5	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				89.00	222.50		89.00	267.00		89.00			222.50								89.00			
S5715	002	0		29	10	S5715_002_0	3	1	4	1	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	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	3	3	4	1	Brand	000010	1	2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				75.00	187.50		75.00	225.00		75.00			187.50								75.00			
S5715	002	0		29	10	S5715_002_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	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	3	4	4	3	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																						1	2	01000000
S5715	002	0		29	10	S5715_002_0	3	3	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
S5715	002	0		29	10	S5715_002_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5715	002	0		29	10	S5715_002_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5715	002	0		29	10	S5715_002_0	3	1	4	3	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00	1	1	
S5715	003	0		29	10	S5715_003_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	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	5	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				32	32		32	32		32											32	Specialty																								
S5715	003	0		29	10	S5715_003_0	5	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				89.00	222.50		89.00	267.00		89.00			222.50								89.00			
S5715	003	0		29	10	S5715_003_0	5	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				12.00	30.00		12.00	36.00		12.00			30.00								12.00			
S5715	004	0		29	10	S5715_004_0	3	3	4	1	Brand	000010	1	2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				75.00	187.50		75.00	225.00		75.00			187.50								75.00			
S5715	004	0		29	10	S5715_004_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	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	3	1	4	1	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	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	3	4	4	3	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																						1	2	01000000
S5715	004	0		29	10	S5715_004_0	3	1	4	3	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00	1	1	
S5715	004	0		29	10	S5715_004_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5715	004	0		29	10	S5715_004_0	3	3	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
S5715	004	0		29	10	S5715_004_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5715	005	0		29	10	S5715_005_0	5	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5715	005	0		29	10	S5715_005_0	5	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				88.00	220.00		88.00	264.00		88.00			220.00								88.00			
S5715	005	0		29	10	S5715_005_0	5	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				11.00	27.50		11.00	33.00		11.00			27.50								11.00			
S5715	005	0		29	10	S5715_005_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				45.00	112.50		45.00	135.00		45.00			112.50								45.00			
S5715	006	0		29	10	S5715_006_0	3	1	4	3	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00	1	1	
S5715	006	0		29	10	S5715_006_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5715	006	0		29	10	S5715_006_0	3	3	4	1	Brand	000010	1	2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				75.00	187.50		75.00	225.00		75.00			187.50								75.00			
S5715	006	0		29	10	S5715_006_0	3	3	4	3	Brand	000010	1	2	1	Brand																								Brand		Brand																						Brand																						2		
S5715	006	0		29	10	S5715_006_0	3	4	4	3	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																						1	2	01000000
S5715	006	0		29	10	S5715_006_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				33	33		33	33		33											33	Specialty																								
S5715	006	0		29	10	S5715_006_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	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	3	1	4	1	Generic	010000	1	2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				5.00	12.50		5.00	15.00		5.00			12.50								5.00			
S5715	007	0		29	10	S5715_007_0	4	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
S5715	007	0		29	10	S5715_007_0	4	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				78.00	195.00		78.00	234.00		78.00			195.00								78.00			
S5715	007	0		29	10	S5715_007_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				27.00	67.50		27.00	81.00		27.00			67.50								27.00			
S5715	007	0		29	10	S5715_007_0	4	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				3.00	7.50		3.00	9.00		3.00			7.50								3.00			
S5715	008	0		29	10	S5715_008_0	4	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
S5715	008	0		29	10	S5715_008_0	4	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				79.00	197.50		79.00	237.00		79.00			197.50								79.00			
S5715	008	0		29	10	S5715_008_0	4	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				3.00	7.50		3.00	9.00		3.00			7.50								3.00			
S5715	008	0		29	10	S5715_008_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				29.00	72.50		29.00	87.00		29.00			72.50								29.00			
S5715	009	0		29	10	S5715_009_0	4	3	3	1	Brand	000010		2	1	Brand	100011011010010000000				30	90		30	90		30			90								31	1	Brand	2	Brand																						Brand				83.00	207.50		83.00	249.00		83.00			207.50								83.00			
S5715	009	0		29	10	S5715_009_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	100011011010010000000				30	90		30	90		30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand				33.00	82.50		33.00	99.00		33.00			82.50								33.00			
S5715	009	0		29	10	S5715_009_0	4	1	3	1	Generic	010000		2	2	Generic	100011011010010000000				30	90		30	90		30			90								31	1	Generic	2	Generic																						Generic				3.00	7.50		3.00	9.00		3.00			7.50								3.00			
S5715	009	0		29	10	S5715_009_0	4	4	3	1	Specialty	010010		1	2	Specialty	100011011010000000000				30	90		30	90		30											31	1	Specialty	1	Specialty				25	25		25	25		25											25	Specialty																								
S5726	013	0		29	10	S5726_013_0	2	1	3	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5726	013	0		29	10	S5726_013_0	2	2	3	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	42.00	126.00								42.00						105.00			126.00		42.00			
S5726	013	0		29	10	S5726_013_0	2	3	3	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	29	29								29						29			29		29	Tier 3 Non-Specialty Injectable Drugs																								
S5726	013	0		29	10	S5726_013_0	2	4	3	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	29									29					29			29			29	Tier 4 Specialty Drugs																								
S5726	014	0		29	10	S5726_014_0	1	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5726	014	0		29	10	S5726_014_0	1	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5726	014	0		29	10	S5726_014_0	1	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5726	014	0		29	10	S5726_014_0	1	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5726	014	0		29	10	S5726_014_0	1	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5726	015	0		29	10	S5726_015_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5726	015	0		29	10	S5726_015_0	3	1	4	3	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00	1	1	
S5726	015	0		29	10	S5726_015_0	3	2	4	3	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs																								Tier 2 Preferred Brand  Certain Generic Drugs		Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs																						2		
S5726	015	0		29	10	S5726_015_0	3	3	4	3	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs																								Tier 3 Non-Preferred Brand  Certain Generic Drugs		Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs																						2		
S5726	015	0		29	10	S5726_015_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5726	015	0		29	10	S5726_015_0	3	5	4	3	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs																								Tier 5 Specialty Drugs		Tier 5 Specialty Drugs																						Tier 5 Specialty Drugs																						2		
S5726	015	0		29	10	S5726_015_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5726	015	0		29	10	S5726_015_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5726	015	0		29	10	S5726_015_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5726	015	0		29	10	S5726_015_0	3	4	4	3	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs																								Tier 4 Non-Specialty Injectable Drugs		Tier 4 Non-Specialty Injectable Drugs																						Tier 4 Non-Specialty Injectable Drugs																						2		
S5741	001	0		29	10	S5741_001_0	3	1	2	1	Tier #1	001000		2	2	Tier #1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #1	2	Tier #1																						Tier #1				4.00	8.00	12.00	4.00	12.00	12.00	4.00		4.00	8.00	8.00							4.00			
S5741	001	0		29	10	S5741_001_0	3	2	2	1	Tier #2	000001		2	2	Tier #2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #2	1	Tier #2				25	25	25	25	25	25	25		25	25	25							25	Tier #2																								
S5741	001	0		29	10	S5741_001_0	3	3	2	1	Tier #3	100100		2	1	Tier #3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #3	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	4	2	1	Tier #4	010010		1	2	Tier #4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #4	1	Tier #4				25	25	25	25	25	25	25		25	25	25							25	Tier #4																								
S5741	003	0		29	10	S5741_003_0	3	3	4	3	Tier #3	100100	1	2	1	Tier #3																								Tier #3		Tier #3																						Tier #3																						2		
S5741	003	0		29	10	S5741_003_0	3	4	4	3	Tier #4	010010	1	1	2	Tier #4																								Tier #4		Tier #4																						Tier #4																						2		
S5741	003	0		29	10	S5741_003_0	3	2	4	3	Tier #2	000001	1	2	2	Tier #2																								Tier #2		Tier #2																						Tier #2																						2		
S5741	003	0		29	10	S5741_003_0	3	1	4	3	Tier #1	001000	1	2	2	Tier #1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #1	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	1	1	
S5741	003	0		29	10	S5741_003_0	3	1	4	1	Tier #1	001000	1	2	2	Tier #1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #1	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	3	2	4	1	Tier #2	000001	1	2	2	Tier #2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #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	3	3	4	1	Tier #3	100100	1	2	1	Tier #3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #3	1	Tier #3				40	40	40	40	40	40	40		40	40	40							40	Tier #3																								
S5741	003	0		29	10	S5741_003_0	3	4	4	1	Tier #4	010010	1	1	2	Tier #4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #4	1	Tier #4				25	25	25	25	25	25	25		25	25	25							25	Tier #4																								
S5743	001	0		29	10	S5743_001_0	1	4	2	1	Covered Specialty	011110		1	2	Covered Specialty	111000000010010000000	31	90								31			90								31	1	Covered Specialty	1	Covered Specialty	25	25								25			25								25	Covered Specialty																								
S5743	001	0		29	10	S5743_001_0	1	3	2	1	Level 3: Covered Brand	100000		2	1	Level 3: Covered Brand	111000000010010000000	31	90								31			90								31	1	Level 3: Covered Brand	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																								
S5743	001	0		29	10	S5743_001_0	1	2	2	1	Level 2: Covered Preferred Brand	000001		2	2	Level 2: Covered Preferred Brand	111000000010010000000	31	90								31			90								31	1	Level 2: Covered Preferred Brand	1	Level 2: Covered Preferred Brand	22	22								22			22								22	Level 2: Covered Preferred Brand																								
S5743	001	0		29	10	S5743_001_0	1	1	2	1	Level 1: Covered Generics	010000		2	2	Level 1: Covered Generics	111000000010010000000	31	90								31			90								31	1	Level 1: Covered Generics	1	Level 1: Covered Generics	10	10								10			10								10	Level 1: Covered Generics																								
S5743	003	0		29	10	S5743_003_0	2	3	4	1	Level 3: Covered Brand	100000	1	2	1	Level 3: Covered Brand	111000000010010000000	31	90								31			90								31	1	Level 3: Covered Brand	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																								
S5743	003	0		29	10	S5743_003_0	2	4	4	1	Covered Specialty	011110	1	1	2	Covered Specialty	111000000010010000000	31	90								31			90								31	1	Covered Specialty	1	Covered Specialty	28	28								28			28								28	Covered Specialty																								
S5743	003	0		29	10	S5743_003_0	2	2	4	1	Level 2: Covered Preferred Brand	000001	1	2	2	Level 2: Covered Preferred Brand	111000000010010000000	31	90								31			90								31	1	Level 2: Covered Preferred Brand	2	Level 2: Covered Preferred Brand																						Level 2: Covered Preferred Brand	35.00	105.00								35.00			70.00								35.00			
S5743	003	0		29	10	S5743_003_0	2	1	4	1	Level 1: Covered Generic	010000	1	2	2	Level 1: Covered Generic	111000000010010000000	31	90								31			90								31	1	Level 1: Covered Generic	2	Level 1: Covered Generic																						Level 1: Covered Generic	4.00	12.00								4.00			8.00								4.00			
S5743	004	0		29	10	S5743_004_0	2	4	4	1	Covered Specialty	110011	1	1	2	Covered Specialty	111000000010010000000	31	90								31			90								31	1	Covered Specialty	1	Covered Specialty	33	33								33			33								33	Covered Specialty																								
S5743	004	0		29	10	S5743_004_0	2	3	4	1	Level 3: Covered Brand	100000	1	2	1	Level 3: Covered Brand	111000000010010000000	31	90								31			90								31	1	Level 3: Covered Brand	1	Level 3: Covered Brand	50	50								50			50								50	Level 3: Covered Brand																								
S5743	004	0		29	10	S5743_004_0	2	2	4	1	Level 2: Covered Preferred Brand	000001	1	2	2	Level 2: Covered Preferred Brand	111000000010010000000	31	90								31			90								31	1	Level 2: Covered Preferred Brand	2	Level 2: Covered Preferred Brand																						Level 2: Covered Preferred Brand	38.00	114.00								38.00			76.00								38.00			
S5743	004	0		29	10	S5743_004_0	2	1	4	1	Level 1: Covered Generic	010000	1	2	2	Level 1: Covered Generic	111000000010010000000	31	90								31			90								31	1	Level 1: Covered Generic	2	Level 1: Covered Generic																						Level 1: Covered Generic	4.00	12.00								4.00			8.00								4.00			
S5743	004	0		29	10	S5743_004_0	2	1	4	3	Level 1: Covered Generic	010000	1	2	2	Level 1: Covered Generic	111000000010010000000	31	90								31			90								31	1	Level 1: Covered Generic	2	Level 1: Covered Generic																						Level 1: Covered Generic	4.00	12.00								4.00			8.00								4.00	1	1	
S5743	004	0		29	10	S5743_004_0	2	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																						2		
S5743	004	0		29	10	S5743_004_0	2	3	4	3	Level 3: Covered Brand	100000	1	2	1	Level 3: Covered Brand																								Level 3: Covered Brand		Level 3: Covered Brand																						Level 3: Covered Brand																						2		
S5743	004	0		29	10	S5743_004_0	2	4	4	3	Covered Specialty	110011	1	1	2	Covered Specialty																								Covered Specialty		Covered Specialty																						Covered Specialty																						2		
S5753	006	0		29	10	S5753_006_0	1	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010110000000	30	90	60							30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00	136.00							68.00		68.00	170.00								68.00			
S5753	006	0		29	10	S5753_006_0	1	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00		39.00	97.50								39.00			
S5753	006	0		29	10	S5753_006_0	1	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010110000000	30	90	60							30		30	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	13.00	39.00	26.00							13.00		13.00	32.50								13.00			
S5753	006	0		29	10	S5753_006_0	1	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00	12.00							6.00		6.00	15.00								6.00			
S5753	006	0		29	10	S5753_006_0	1	5	4	1	Specialty Brand	000010	1	1	2	Specialty Brand	111100000010110000000	30	90	60							30		30	90								31	1	Specialty Brand	1	Specialty Brand	33	33	33							33		33	33								33	Specialty Brand																								
S5753	007	0		29	10	S5753_007_0	2	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00	12.00							6.00		6.00	15.00								6.00	1	1	
S5753	007	0		29	10	S5753_007_0	2	2	4	3	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010110000000	30	90	60							30		30	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	13.00	39.00	26.00							13.00		13.00	32.50								13.00	1	1	
S5753	007	0		29	10	S5753_007_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5753	007	0		29	10	S5753_007_0	2	4	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5753	007	0		29	10	S5753_007_0	2	5	4	1	Specialty Brand	000010	1	1	2	Specialty Brand	111100000010110000000	30	90	60							30		30	90								31	1	Specialty Brand	1	Specialty Brand	33	33	33							33		33	33								33	Specialty Brand																								
S5753	007	0		29	10	S5753_007_0	2	4	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111100000010110000000	30	90	60							30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	68.00	204.00	136.00							68.00		68.00	170.00								68.00			
S5753	007	0		29	10	S5753_007_0	2	5	4	3	Specialty Brand	000010	1	1	2	Specialty Brand																								Specialty Brand		Specialty Brand																						Specialty Brand																						2		
S5753	007	0		29	10	S5753_007_0	2	2	4	1	Non-Preferred Generic	000100	1	2	2	Non-Preferred Generic	111100000010110000000	30	90	60							30		30	90								31	1	Non-Preferred Generic	2	Non-Preferred Generic																						Non-Preferred Generic	13.00	39.00	26.00							13.00		13.00	32.50								13.00			
S5753	007	0		29	10	S5753_007_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								31	1	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00	12.00							6.00		6.00	15.00								6.00			
S5753	007	0		29	10	S5753_007_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00	78.00							39.00		39.00	97.50								39.00			
S5755	005	0		29	10	S5755_005_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00			
S5755	005	0		29	10	S5755_005_0	4	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	88.00								35.00			70.00								35.00			
S5755	005	0		29	10	S5755_005_0	4	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			140.00								70.00			
S5755	005	0		29	10	S5755_005_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	006	0		29	10	S5755_006_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	006	0		29	10	S5755_006_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	006	0		29	10	S5755_006_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	006	0		29	10	S5755_006_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	007	0		29	10	S5755_007_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	007	0		29	10	S5755_007_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	007	0		29	10	S5755_007_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	007	0		29	10	S5755_007_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	008	0		29	10	S5755_008_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	008	0		29	10	S5755_008_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	180.00								72.00			144.00								72.00			
S5755	008	0		29	10	S5755_008_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00			
S5755	008	0		29	10	S5755_008_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00			
S5755	009	0		29	10	S5755_009_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	009	0		29	10	S5755_009_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	009	0		29	10	S5755_009_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	009	0		29	10	S5755_009_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	010	0		29	10	S5755_010_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	180.00								72.00			144.00								72.00			
S5755	010	0		29	10	S5755_010_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	010	0		29	10	S5755_010_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00			
S5755	010	0		29	10	S5755_010_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00			
S5755	011	0		29	10	S5755_011_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	011	0		29	10	S5755_011_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	195.00								78.00			156.00								78.00			
S5755	011	0		29	10	S5755_011_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	98.00								39.00			78.00								39.00			
S5755	011	0		29	10	S5755_011_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	10.00	28.00								10.00			26.00								10.00			
S5755	012	0		29	10	S5755_012_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	012	0		29	10	S5755_012_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	012	0		29	10	S5755_012_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	012	0		29	10	S5755_012_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	013	0		29	10	S5755_013_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	013	0		29	10	S5755_013_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	013	0		29	10	S5755_013_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	013	0		29	10	S5755_013_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	014	0		29	10	S5755_014_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	014	0		29	10	S5755_014_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	014	0		29	10	S5755_014_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	014	0		29	10	S5755_014_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	015	0		29	10	S5755_015_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	015	0		29	10	S5755_015_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	015	0		29	10	S5755_015_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	015	0		29	10	S5755_015_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	016	0		29	10	S5755_016_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	6.00	17.00								6.00			15.00								6.00			
S5755	016	0		29	10	S5755_016_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	016	0		29	10	S5755_016_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	88.00								35.00			70.00								35.00			
S5755	016	0		29	10	S5755_016_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	175.00								70.00			140.00								70.00			
S5755	017	0		29	10	S5755_017_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	017	0		29	10	S5755_017_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00			
S5755	017	0		29	10	S5755_017_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00			
S5755	017	0		29	10	S5755_017_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	180.00								72.00			144.00								72.00			
S5755	018	0		29	10	S5755_018_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00			
S5755	018	0		29	10	S5755_018_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00			
S5755	018	0		29	10	S5755_018_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	180.00								72.00			144.00								72.00			
S5755	018	0		29	10	S5755_018_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	019	0		29	10	S5755_019_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	10.00	28.00								10.00			26.00								10.00			
S5755	019	0		29	10	S5755_019_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	98.00								39.00			78.00								39.00			
S5755	019	0		29	10	S5755_019_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	195.00								78.00			156.00								78.00			
S5755	019	0		29	10	S5755_019_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	020	0		29	10	S5755_020_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	020	0		29	10	S5755_020_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	020	0		29	10	S5755_020_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	020	0		29	10	S5755_020_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	021	0		29	10	S5755_021_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00			
S5755	021	0		29	10	S5755_021_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	180.00								72.00			144.00								72.00			
S5755	021	0		29	10	S5755_021_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00			
S5755	021	0		29	10	S5755_021_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	022	0		29	10	S5755_022_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	98.00								39.00			78.00								39.00			
S5755	022	0		29	10	S5755_022_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	195.00								78.00			156.00								78.00			
S5755	022	0		29	10	S5755_022_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	022	0		29	10	S5755_022_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	10.00	28.00								10.00			26.00								10.00			
S5755	023	0		29	10	S5755_023_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	023	0		29	10	S5755_023_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	023	0		29	10	S5755_023_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	023	0		29	10	S5755_023_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	024	0		29	10	S5755_024_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	024	0		29	10	S5755_024_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	024	0		29	10	S5755_024_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	024	0		29	10	S5755_024_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	025	0		29	10	S5755_025_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	025	0		29	10	S5755_025_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	025	0		29	10	S5755_025_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	025	0		29	10	S5755_025_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	026	0		29	10	S5755_026_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	026	0		29	10	S5755_026_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	026	0		29	10	S5755_026_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	026	0		29	10	S5755_026_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	027	0		29	10	S5755_027_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	027	0		29	10	S5755_027_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	027	0		29	10	S5755_027_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	027	0		29	10	S5755_027_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	028	0		29	10	S5755_028_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	028	0		29	10	S5755_028_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	180.00								72.00			144.00								72.00			
S5755	028	0		29	10	S5755_028_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00			72.00								36.00			
S5755	028	0		29	10	S5755_028_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	7.00	20.00								7.00			18.00								7.00			
S5755	029	0		29	10	S5755_029_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	029	0		29	10	S5755_029_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	029	0		29	10	S5755_029_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	029	0		29	10	S5755_029_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	030	0		29	10	S5755_030_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	030	0		29	10	S5755_030_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	030	0		29	10	S5755_030_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	030	0		29	10	S5755_030_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	031	0		29	10	S5755_031_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	031	0		29	10	S5755_031_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	031	0		29	10	S5755_031_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	031	0		29	10	S5755_031_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	032	0		29	10	S5755_032_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	032	0		29	10	S5755_032_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	032	0		29	10	S5755_032_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	032	0		29	10	S5755_032_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	033	0		29	10	S5755_033_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	8.00	23.00								8.00			21.00								8.00			
S5755	033	0		29	10	S5755_033_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	37.00	93.00								37.00			74.00								37.00			
S5755	033	0		29	10	S5755_033_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	033	0		29	10	S5755_033_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	74.00	185.00								74.00			148.00								74.00			
S5755	034	0		29	10	S5755_034_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	034	0		29	10	S5755_034_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	034	0		29	10	S5755_034_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	034	0		29	10	S5755_034_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	035	0		29	10	S5755_035_0	1	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	10.00	28.00								10.00			26.00								10.00			
S5755	035	0		29	10	S5755_035_0	1	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	98.00								39.00			78.00								39.00			
S5755	035	0		29	10	S5755_035_0	1	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	035	0		29	10	S5755_035_0	1	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	195.00								78.00			156.00								78.00			
S5755	038	0		29	10	S5755_038_0	2	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00			152.00								76.00			
S5755	038	0		29	10	S5755_038_0	2	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	38.00	95.00								38.00			76.00								38.00			
S5755	038	0		29	10	S5755_038_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	9.00	25.00								9.00			23.00								9.00			
S5755	038	0		29	10	S5755_038_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	039	0		29	10	S5755_039_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	10.00	28.00								10.00			26.00								10.00			
S5755	039	0		29	10	S5755_039_0	3	2	4	1	Preferred Brand	010011	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	98.00								39.00			78.00								39.00			
S5755	039	0		29	10	S5755_039_0	3	3	4	1	Non-Preferred Brand	110010	1	2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	195.00								78.00			156.00								78.00			
S5755	039	0		29	10	S5755_039_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5755	040	0		29	10	S5755_040_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	040	0		29	10	S5755_040_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	040	0		29	10	S5755_040_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	040	0		29	10	S5755_040_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	041	0		29	10	S5755_041_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	041	0		29	10	S5755_041_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	041	0		29	10	S5755_041_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	042	0		29	10	S5755_042_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	042	0		29	10	S5755_042_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	042	0		29	10	S5755_042_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	042	0		29	10	S5755_042_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	043	0		29	10	S5755_043_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	043	0		29	10	S5755_043_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	043	0		29	10	S5755_043_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	043	0		29	10	S5755_043_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	044	0		29	10	S5755_044_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	044	0		29	10	S5755_044_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	044	0		29	10	S5755_044_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	044	0		29	10	S5755_044_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	045	0		29	10	S5755_045_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	045	0		29	10	S5755_045_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	045	0		29	10	S5755_045_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	045	0		29	10	S5755_045_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	046	0		29	10	S5755_046_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	046	0		29	10	S5755_046_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	046	0		29	10	S5755_046_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	047	0		29	10	S5755_047_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	047	0		29	10	S5755_047_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	047	0		29	10	S5755_047_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	047	0		29	10	S5755_047_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	048	0		29	10	S5755_048_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	048	0		29	10	S5755_048_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	048	0		29	10	S5755_048_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	049	0		29	10	S5755_049_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	049	0		29	10	S5755_049_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	049	0		29	10	S5755_049_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	049	0		29	10	S5755_049_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	050	0		29	10	S5755_050_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	050	0		29	10	S5755_050_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	050	0		29	10	S5755_050_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	050	0		29	10	S5755_050_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	051	0		29	10	S5755_051_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	051	0		29	10	S5755_051_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	051	0		29	10	S5755_051_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	051	0		29	10	S5755_051_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	052	0		29	10	S5755_052_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	052	0		29	10	S5755_052_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	052	0		29	10	S5755_052_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	053	0		29	10	S5755_053_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	053	0		29	10	S5755_053_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	053	0		29	10	S5755_053_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	053	0		29	10	S5755_053_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	054	0		29	10	S5755_054_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	054	0		29	10	S5755_054_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	054	0		29	10	S5755_054_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	054	0		29	10	S5755_054_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	055	0		29	10	S5755_055_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	055	0		29	10	S5755_055_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	056	0		29	10	S5755_056_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	056	0		29	10	S5755_056_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	056	0		29	10	S5755_056_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	056	0		29	10	S5755_056_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	057	0		29	10	S5755_057_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	057	0		29	10	S5755_057_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	057	0		29	10	S5755_057_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	057	0		29	10	S5755_057_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	058	0		29	10	S5755_058_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	058	0		29	10	S5755_058_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	058	0		29	10	S5755_058_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	058	0		29	10	S5755_058_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	059	0		29	10	S5755_059_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	059	0		29	10	S5755_059_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	059	0		29	10	S5755_059_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	059	0		29	10	S5755_059_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	060	0		29	10	S5755_060_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	060	0		29	10	S5755_060_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	060	0		29	10	S5755_060_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	061	0		29	10	S5755_061_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	061	0		29	10	S5755_061_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	061	0		29	10	S5755_061_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	062	0		29	10	S5755_062_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	062	0		29	10	S5755_062_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	062	0		29	10	S5755_062_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	063	0		29	10	S5755_063_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	063	0		29	10	S5755_063_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	063	0		29	10	S5755_063_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	064	0		29	10	S5755_064_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	064	0		29	10	S5755_064_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	064	0		29	10	S5755_064_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	065	0		29	10	S5755_065_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	065	0		29	10	S5755_065_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	065	0		29	10	S5755_065_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	066	0		29	10	S5755_066_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	066	0		29	10	S5755_066_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	066	0		29	10	S5755_066_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	067	0		29	10	S5755_067_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	067	0		29	10	S5755_067_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	067	0		29	10	S5755_067_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	068	0		29	10	S5755_068_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	068	0		29	10	S5755_068_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	068	0		29	10	S5755_068_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	069	0		29	10	S5755_069_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	069	0		29	10	S5755_069_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	069	0		29	10	S5755_069_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	070	0		29	10	S5755_070_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	070	0		29	10	S5755_070_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	070	0		29	10	S5755_070_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	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	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	071	0		29	10	S5755_071_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	071	0		29	10	S5755_071_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5755	071	0		29	10	S5755_071_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	071	0		29	10	S5755_071_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	072	0		29	10	S5755_072_0	1	3	3	1	Non-Preferred Brand	110010		2	1	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	90.00	270.00								90.00			225.00								90.00			
S5755	072	0		29	10	S5755_072_0	1	2	3	1	Preferred Brand	010011		2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	45.00	135.00								45.00			113.00								45.00			
S5755	072	0		29	10	S5755_072_0	1	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	34	90								34			90								34	1	Generic	2	Generic																						Generic	4.00	12.00								4.00			10.00								4.00			
S5755	072	0		29	10	S5755_072_0	1	4	3	1	Specialty	010010		1	2	Specialty	111000000010010000000	34	90								34			90								34	1	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5766	002	0		29	10	S5766_002_0	4	1	3	1	Generic	010000		2	2	Generic	111000000010000000000	34	90								34											34	2	Generic	2	Generic																						Generic	10.00	20.00								10.00											10.00			
S5766	002	0		29	10	S5766_002_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	34	90								34											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00											30.00			
S5766	002	0		29	10	S5766_002_0	4	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	34	90								34											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	140.00								70.00											70.00			
S5766	002	0		29	10	S5766_002_0	4	4	3	1	Non-Self Injectable	000010		2	2	Non-Self Injectable	111000000010000000000	34	90								34											34	2	Non-Self Injectable	1	Non-Self Injectable	25	25								25											25	Non-Self Injectable																								
S5766	003	0		29	10	S5766_003_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	34	90								34											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	60.00								30.00											30.00			
S5766	003	0		29	10	S5766_003_0	4	4	4	3	Non-Self Injectables	000010	1	2	2	Non-Self Injectables																								Non-Self Injectables		Non-Self Injectables																						Non-Self Injectables																						2		
S5766	003	0		29	10	S5766_003_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5766	003	0		29	10	S5766_003_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5766	003	0		29	10	S5766_003_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	34	90								34											34	2	Generic	2	Generic																						Generic	10.00	20.00								10.00											10.00	1	1	
S5766	003	0		29	10	S5766_003_0	4	4	4	1	Non-Self Injectables	000010	1	2	2	Non-Self Injectables	111000000010000000000	34	90								34											34	2	Non-Self Injectables	1	Non-Self Injectables	25	25								25											25	Non-Self Injectables																								
S5766	003	0		29	10	S5766_003_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	34	90								34											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	140.00								70.00											70.00			
S5766	003	0		29	10	S5766_003_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	34	90								34											34	2	Generic	2	Generic																						Generic	10.00	20.00								10.00											10.00			
S5768	005	0		29	10	S5768_005_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	005	0		29	10	S5768_005_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	45	45								45			45								45	Non-Preferred Generic/Non-Preferred Brand																								
S5768	005	0		29	10	S5768_005_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	005	0		29	10	S5768_005_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	007	0		29	10	S5768_007_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	007	0		29	10	S5768_007_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	007	0		29	10	S5768_007_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	007	0		29	10	S5768_007_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	008	0		29	10	S5768_008_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	008	0		29	10	S5768_008_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	45	45								45			45								45	Non-Preferred Generic/Non-Preferred Brand																								
S5768	008	0		29	10	S5768_008_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	008	0		29	10	S5768_008_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	009	0		29	10	S5768_009_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	009	0		29	10	S5768_009_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	009	0		29	10	S5768_009_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	009	0		29	10	S5768_009_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	010	0		29	10	S5768_010_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	010	0		29	10	S5768_010_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	010	0		29	10	S5768_010_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	010	0		29	10	S5768_010_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	45	45								45			45								45	Non-Preferred Generic/Non-Preferred Brand																								
S5768	012	0		29	10	S5768_012_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	012	0		29	10	S5768_012_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	012	0		29	10	S5768_012_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	012	0		29	10	S5768_012_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	015	0		29	10	S5768_015_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	015	0		29	10	S5768_015_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	015	0		29	10	S5768_015_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	015	0		29	10	S5768_015_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	016	0		29	10	S5768_016_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	016	0		29	10	S5768_016_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	016	0		29	10	S5768_016_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	016	0		29	10	S5768_016_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	017	0		29	10	S5768_017_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	017	0		29	10	S5768_017_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	017	0		29	10	S5768_017_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	017	0		29	10	S5768_017_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	018	0		29	10	S5768_018_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	018	0		29	10	S5768_018_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	018	0		29	10	S5768_018_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	018	0		29	10	S5768_018_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	021	0		29	10	S5768_021_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	021	0		29	10	S5768_021_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	021	0		29	10	S5768_021_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	021	0		29	10	S5768_021_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic/Non-Preferred Brand																								
S5768	031	0		29	10	S5768_031_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00			27.00								9.00			
S5768	031	0		29	10	S5768_031_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	031	0		29	10	S5768_031_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic/Non-Preferred Brand																								
S5768	031	0		29	10	S5768_031_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	038	0		29	10	S5768_038_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00			24.00								8.00			
S5768	038	0		29	10	S5768_038_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	038	0		29	10	S5768_038_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	038	0		29	10	S5768_038_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	039	0		29	10	S5768_039_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00			24.00								8.00			
S5768	039	0		29	10	S5768_039_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	039	0		29	10	S5768_039_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic/Non-Preferred Brand																								
S5768	039	0		29	10	S5768_039_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	040	0		29	10	S5768_040_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	040	0		29	10	S5768_040_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	040	0		29	10	S5768_040_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	040	0		29	10	S5768_040_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	47	47								47			47								47	Non-Preferred Generic/Non-Preferred Brand																								
S5768	041	0		29	10	S5768_041_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	10.00	30.00								10.00			30.00								10.00			
S5768	041	0		29	10	S5768_041_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	041	0		29	10	S5768_041_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	41	41								41			41								41	Non-Preferred Generic/Non-Preferred Brand																								
S5768	041	0		29	10	S5768_041_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	042	0		29	10	S5768_042_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	042	0		29	10	S5768_042_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	042	0		29	10	S5768_042_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	042	0		29	10	S5768_042_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	043	0		29	10	S5768_043_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	043	0		29	10	S5768_043_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic/Non-Preferred Brand																								
S5768	043	0		29	10	S5768_043_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00			24.00								8.00			
S5768	043	0		29	10	S5768_043_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	044	0		29	10	S5768_044_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	044	0		29	10	S5768_044_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	42	42								42			42								42	Non-Preferred Generic/Non-Preferred Brand																								
S5768	044	0		29	10	S5768_044_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	044	0		29	10	S5768_044_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	9.00	27.00								9.00			27.00								9.00			
S5768	045	0		29	10	S5768_045_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	045	0		29	10	S5768_045_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	045	0		29	10	S5768_045_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	12	12								12			12								12	Preferred Brand																								
S5768	045	0		29	10	S5768_045_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00			24.00								8.00			
S5768	046	0		29	10	S5768_046_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	046	0		29	10	S5768_046_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	046	0		29	10	S5768_046_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	046	0		29	10	S5768_046_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	047	0		29	10	S5768_047_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	047	0		29	10	S5768_047_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	047	0		29	10	S5768_047_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	047	0		29	10	S5768_047_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	42	42								42			42								42	Non-Preferred Generic/Non-Preferred Brand																								
S5768	048	0		29	10	S5768_048_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	048	0		29	10	S5768_048_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	048	0		29	10	S5768_048_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	43	43								43			43								43	Non-Preferred Generic/Non-Preferred Brand																								
S5768	048	0		29	10	S5768_048_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	082	0		29	10	S5768_082_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	082	0		29	10	S5768_082_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	12	12								12			12								12	Preferred Brand																								
S5768	082	0		29	10	S5768_082_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	082	0		29	10	S5768_082_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	42	42								42			42								42	Non-Preferred Generic/Non-Preferred Brand																								
S5768	083	0		29	10	S5768_083_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	083	0		29	10	S5768_083_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	41	41								41			41								41	Non-Preferred Generic/Non-Preferred Brand																								
S5768	083	0		29	10	S5768_083_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	083	0		29	10	S5768_083_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	084	0		29	10	S5768_084_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	084	0		29	10	S5768_084_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	48	48								48			48								48	Non-Preferred Generic and Non-Preferred Brand																								
S5768	084	0		29	10	S5768_084_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	085	0		29	10	S5768_085_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00			7.50								3.00			
S5768	085	0		29	10	S5768_085_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic and Non-Preferred Brand																								
S5768	085	0		29	10	S5768_085_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	085	0		29	10	S5768_085_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	086	0		29	10	S5768_086_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	086	0		29	10	S5768_086_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	086	0		29	10	S5768_086_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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 and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	087	0		29	10	S5768_087_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	087	0		29	10	S5768_087_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	087	0		29	10	S5768_087_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	087	0		29	10	S5768_087_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	088	0		29	10	S5768_088_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	088	0		29	10	S5768_088_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	088	0		29	10	S5768_088_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	089	0		29	10	S5768_089_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	089	0		29	10	S5768_089_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	089	0		29	10	S5768_089_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5768	090	0		29	10	S5768_090_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	090	0		29	10	S5768_090_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	57	57								57			57								57	Non-Preferred Generic and Non-Preferred Brand																								
S5768	090	0		29	10	S5768_090_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	090	0		29	10	S5768_090_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	091	0		29	10	S5768_091_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	091	0		29	10	S5768_091_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	091	0		29	10	S5768_091_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	55	55								55			55								55	Non-Preferred Generic and Non-Preferred Brand																								
S5768	091	0		29	10	S5768_091_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	092	0		29	10	S5768_092_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	092	0		29	10	S5768_092_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	092	0		29	10	S5768_092_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	093	0		29	10	S5768_093_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	093	0		29	10	S5768_093_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	093	0		29	10	S5768_093_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	093	0		29	10	S5768_093_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic and Non-Preferred Brand																								
S5768	094	0		29	10	S5768_094_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	094	0		29	10	S5768_094_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	094	0		29	10	S5768_094_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	094	0		29	10	S5768_094_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	095	0		29	10	S5768_095_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	095	0		29	10	S5768_095_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	095	0		29	10	S5768_095_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	095	0		29	10	S5768_095_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5768	096	0		29	10	S5768_096_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	096	0		29	10	S5768_096_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	51	51								51			51								51	Non-Preferred Generic and Non-Preferred Brand																								
S5768	096	0		29	10	S5768_096_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	096	0		29	10	S5768_096_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	097	0		29	10	S5768_097_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	097	0		29	10	S5768_097_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	097	0		29	10	S5768_097_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	097	0		29	10	S5768_097_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	55	55								55			55								55	Non-Preferred Generic and Non-Preferred Brand																								
S5768	098	0		29	10	S5768_098_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	098	0		29	10	S5768_098_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	098	0		29	10	S5768_098_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	098	0		29	10	S5768_098_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5768	099	0		29	10	S5768_099_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	099	0		29	10	S5768_099_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	58	58								58			58								58	Non-Preferred Generic and Non-Preferred Brand																								
S5768	099	0		29	10	S5768_099_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	099	0		29	10	S5768_099_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	100	0		29	10	S5768_100_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	100	0		29	10	S5768_100_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	100	0		29	10	S5768_100_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	51	51								51			51								51	Non-Preferred Generic and Non-Preferred Brand																								
S5768	101	0		29	10	S5768_101_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	101	0		29	10	S5768_101_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	101	0		29	10	S5768_101_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	49	49								49			49								49	Non-Preferred Generic and Non-Preferred Brand																								
S5768	102	0		29	10	S5768_102_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	56	56								56			56								56	Non-Preferred Generic and Non-Preferred Brand																								
S5768	102	0		29	10	S5768_102_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	102	0		29	10	S5768_102_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	102	0		29	10	S5768_102_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	103	0		29	10	S5768_103_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	103	0		29	10	S5768_103_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	103	0		29	10	S5768_103_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	59	59								59			59								59	Non-Preferred Generic and Non-Preferred Brand																								
S5768	103	0		29	10	S5768_103_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	104	0		29	10	S5768_104_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	104	0		29	10	S5768_104_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	104	0		29	10	S5768_104_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5768	104	0		29	10	S5768_104_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	105	0		29	10	S5768_105_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	105	0		29	10	S5768_105_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	61	61								61			61								61	Non-Preferred Generic and Non-Preferred Brand																								
S5768	105	0		29	10	S5768_105_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	106	0		29	10	S5768_106_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	106	0		29	10	S5768_106_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	54	54								54			54								54	Non-Preferred Generic and Non-Preferred Brand																								
S5768	106	0		29	10	S5768_106_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	106	0		29	10	S5768_106_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	107	0		29	10	S5768_107_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	107	0		29	10	S5768_107_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	107	0		29	10	S5768_107_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	49	49								49			49								49	Non-Preferred Generic and Non-Preferred Brand																								
S5768	107	0		29	10	S5768_107_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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 and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	53	53								53			53								53	Non-Preferred Generic and Non-Preferred Brand																								
S5768	108	0		29	10	S5768_108_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	108	0		29	10	S5768_108_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	108	0		29	10	S5768_108_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	109	0		29	10	S5768_109_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	109	0		29	10	S5768_109_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	109	0		29	10	S5768_109_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic and Non-Preferred Brand																								
S5768	109	0		29	10	S5768_109_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	110	0		29	10	S5768_110_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	49	49								49			49								49	Non-Preferred Generic and Non-Preferred Brand																								
S5768	110	0		29	10	S5768_110_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	110	0		29	10	S5768_110_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	110	0		29	10	S5768_110_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	111	0		29	10	S5768_111_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	111	0		29	10	S5768_111_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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 and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	112	0		29	10	S5768_112_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	3.00	9.00								3.00			7.50								3.00			
S5768	112	0		29	10	S5768_112_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	112	0		29	10	S5768_112_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	40	40								40			40								40	Non-Preferred Generic and Non-Preferred Brand																								
S5768	112	0		29	10	S5768_112_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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 and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	50	50								50			50								50	Non-Preferred Generic and Non-Preferred Brand																								
S5768	113	0		29	10	S5768_113_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	113	0		29	10	S5768_113_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	113	0		29	10	S5768_113_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	114	0		29	10	S5768_114_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	114	0		29	10	S5768_114_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	114	0		29	10	S5768_114_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	58	58								58			58								58	Non-Preferred Generic and Non-Preferred Brand																								
S5768	114	0		29	10	S5768_114_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	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 and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	115	0		29	10	S5768_115_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	115	0		29	10	S5768_115_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	115	0		29	10	S5768_115_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	116	0		29	10	S5768_116_0	2	4	4	1	Specialty - Generic and Brand	010010	1	1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	28									28											28	Specialty - Generic and Brand																								
S5768	116	0		29	10	S5768_116_0	2	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00								4.00			10.00								4.00			
S5768	116	0		29	10	S5768_116_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	20	20								20			18								20	Preferred Brand																								
S5768	116	0		29	10	S5768_116_0	2	3	4	1	Non-Preferred Generic and Non-Preferred Brand	100100	1	2	1	Non-Preferred Generic and Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic and Non-Preferred Brand	1	Non-Preferred Generic and Non-Preferred Brand	52	52								52			52								52	Non-Preferred Generic and Non-Preferred Brand																								
S5768	117	0		29	10	S5768_117_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	10	10								10			10								10	Preferred Brand																								
S5768	117	0		29	10	S5768_117_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	41	41								41			41								41	Non-Preferred Generic/Non-Preferred Brand																								
S5768	117	0		29	10	S5768_117_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	117	0		29	10	S5768_117_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00			24.00								8.00			
S5768	118	0		29	10	S5768_118_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	118	0		29	10	S5768_118_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	12	12								12			12								12	Preferred Brand																								
S5768	118	0		29	10	S5768_118_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	118	0		29	10	S5768_118_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	119	0		29	10	S5768_119_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	119	0		29	10	S5768_119_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	45	45								45			45								45	Non-Preferred Generic/Non-Preferred Brand																								
S5768	119	0		29	10	S5768_119_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	119	0		29	10	S5768_119_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	8.00	24.00								8.00			24.00								8.00			
S5768	120	0		29	10	S5768_120_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	120	0		29	10	S5768_120_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	46	46								46			46								46	Non-Preferred Generic/Non-Preferred Brand																								
S5768	120	0		29	10	S5768_120_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	120	0		29	10	S5768_120_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	121	0		29	10	S5768_121_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	121	0		29	10	S5768_121_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	121	0		29	10	S5768_121_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	121	0		29	10	S5768_121_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	122	0		29	10	S5768_122_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	122	0		29	10	S5768_122_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	46	46								46			46								46	Non-Preferred Generic/Non-Preferred Brand																								
S5768	122	0		29	10	S5768_122_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	122	0		29	10	S5768_122_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	123	0		29	10	S5768_123_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5768	123	0		29	10	S5768_123_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	45	45								45			45								45	Non-Preferred Generic/Non-Preferred Brand																								
S5768	123	0		29	10	S5768_123_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	123	0		29	10	S5768_123_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	124	0		29	10	S5768_124_0	2	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111000000010010000000	30	90								30			90								31	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	7.00	21.00								7.00			21.00								7.00			
S5768	124	0		29	10	S5768_124_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	2	Preferred Brand	1	Preferred Brand	11	11								11			11								11	Preferred Brand																								
S5768	124	0		29	10	S5768_124_0	2	3	3	1	Non-Preferred Generic/Non-Preferred Brand	100100		2	1	Non-Preferred Generic/Non-Preferred Brand	111000000010010000000	30	90								30			90								31	2	Non-Preferred Generic/Non-Preferred Brand	1	Non-Preferred Generic/Non-Preferred Brand	44	44								44			44								44	Non-Preferred Generic/Non-Preferred Brand																								
S5768	124	0		29	10	S5768_124_0	2	4	3	1	Specialty - Generic and Brand	010010		1	2	Specialty - Generic and Brand	110000000010000000000	30									30											31		Specialty - Generic and Brand	1	Specialty - Generic and Brand	29									29											29	Specialty - Generic and Brand																								
S5775	001	0		29	10	S5775_001_0	1	3	4	1	Nivel 3/ No Preferidos	100000	1	2	1	Nivel 3/ No Preferidos	111000000010000000000	30	90								30											31	1	Nivel 3/ No Preferidos	2	Nivel 3/ No Preferidos																						Nivel 3/ No Preferidos	50.00	150.00								50.00											50.00			
S5775	001	0		29	10	S5775_001_0	1	2	4	1	Nivel 2/ Preferidos	000001	1	2	2	Nivel 2/ Preferidos	111000000010000000000	30	90								30											31	1	Nivel 2/ Preferidos	2	Nivel 2/ Preferidos																						Nivel 2/ Preferidos	25.00	75.00								25.00											25.00			
S5775	001	0		29	10	S5775_001_0	1	1	4	1	Nivel 1/Genricos	010000	1	2	2	Nivel 1/Genricos	111000000010000000000	30	90								30											31	1	Nivel 1/Genricos	2	Nivel 1/Genricos																						Nivel 1/Genricos	3.00	9.00								3.00											3.00			
S5775	001	0		29	10	S5775_001_0	1	4	4	1	Nivel 4/ Especializados	100000	1	1	2	Nivel 4/ Especializados	110000000010000000000	30									30											31		Nivel 4/ Especializados	1	Nivel 4/ Especializados	30									30											30	Nivel 4/ Especializados																								
S5775	002	0		29	10	S5775_002_0	2	3	3	1	Nivel 3/ No Preferidos	100000		2	1	Nivel 3/ No Preferidos	111000000010000000000	30	90								30											31	1	Nivel 3/ No Preferidos	2	Nivel 3/ No Preferidos																						Nivel 3/ No Preferidos	60.00	180.00								60.00											60.00			
S5775	002	0		29	10	S5775_002_0	2	2	3	1	Nivel 2/ Preferidos	000001		2	2	Nivel 2/ Preferidos	111000000010000000000	30	90								30											31	1	Nivel 2/ Preferidos	2	Nivel 2/ Preferidos																						Nivel 2/ Preferidos	30.00	90.00								30.00											30.00			
S5775	002	0		29	10	S5775_002_0	2	1	3	1	Nivel 1/ Genricos	010000		2	2	Nivel 1/ Genricos	111000000010000000000	30	90								30											31	1	Nivel 1/ Genricos	2	Nivel 1/ Genricos																						Nivel 1/ Genricos	3.00	9.00								3.00											3.00			
S5775	002	0		29	10	S5775_002_0	2	4	3	1	Nivel 4/ Especializados	100000		1	2	Nivel 4/ Especializados	110000000010000000000	30									30											31		Nivel 4/ Especializados	1	Nivel 4/ Especializados	27									27											27	Nivel 4/ Especializados																								
S5775	003	0		29	10	S5775_003_0	2	1	4	1	Nivel 1/ Genricos	010000	1	2	2	Nivel 1/ Genricos	111000000010000000000	30	90								30											31	1	Nivel 1/ Genricos	2	Nivel 1/ Genricos																						Nivel 1/ Genricos	3.00	9.00								3.00											3.00			
S5775	003	0		29	10	S5775_003_0	2	2	4	1	Nivel 2/ Preferidos	100000	1	2	2	Nivel 2/ Preferidos	111000000010000000000	30	90								30											31	1	Nivel 2/ Preferidos	2	Nivel 2/ Preferidos																						Nivel 2/ Preferidos	25.00	75.00								25.00											25.00			
S5775	003	0		29	10	S5775_003_0	2	3	4	1	Nivel 3/ No Preferidos	100000	1	2	1	Nivel 3/ No Preferidos	111000000010000000000	30	90								30											31	1	Nivel 3/ No Preferidos	2	Nivel 3/ No Preferidos																						Nivel 3/ No Preferidos	50.00	150.00								50.00											50.00			
S5775	003	0		29	10	S5775_003_0	2	4	4	1	Nivel 4/ Especializados	100000	1	1	2	Nivel 4/ Especializados	110000000010000000000	30									30											31		Nivel 4/ Especializados	1	Nivel 4/ Especializados	25									25											25	Nivel 4/ Especializados																								
S5775	003	0		29	10	S5775_003_0	2	1	4	3	Nivel 1/ Genricos	010000	1	2	2	Nivel 1/ Genricos	111000000010000000000	30	90								30											31	1	Nivel 1/ Genricos	2	Nivel 1/ Genricos																						Nivel 1/ Genricos	3.00	9.00								3.00											3.00	1	1	
S5775	003	0		29	10	S5775_003_0	2	2	4	3	Nivel 2/ Preferidos	100000	1	2	2	Nivel 2/ Preferidos																								Nivel 2/ Preferidos		Nivel 2/ Preferidos																						Nivel 2/ Preferidos																						2		
S5775	003	0		29	10	S5775_003_0	2	3	4	3	Nivel 3/ No Preferidos	100000	1	2	1	Nivel 3/ No Preferidos																								Nivel 3/ No Preferidos		Nivel 3/ No Preferidos																						Nivel 3/ No Preferidos																						2		
S5775	003	0		29	10	S5775_003_0	2	4	4	3	Nivel 4/ Especializados	100000	1	1	2	Nivel 4/ Especializados																								Nivel 4/ Especializados		Nivel 4/ Especializados																						Nivel 4/ Especializados																						2		
S5795	002	0		29	10	S5795_002_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00	1	1	
S5795	002	0		29	10	S5795_002_0	4	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
S5795	002	0		29	10	S5795_002_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
S5795	002	0		29	10	S5795_002_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
S5795	002	0		29	10	S5795_002_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	5.00	12.50								5.00		5.00	12.50								5.00			
S5795	002	0		29	10	S5795_002_0	4	4	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5795	002	0		29	10	S5795_002_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5795	002	0		29	10	S5795_002_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5795	003	0		29	10	S5795_003_0	3	4	3	1	Specialty	000010		1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	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	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
S5795	003	0		29	10	S5795_003_0	3	1	3	1	Generic	010000		2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	6.00	15.00								6.00		6.00	15.00								6.00			
S5795	003	0		29	10	S5795_003_0	3	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
S5795	006	0		29	10	S5795_006_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	76.00	190.00								76.00		76.00	190.00								76.00			
S5795	006	0		29	10	S5795_006_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	90.00								36.00		36.00	90.00								36.00			
S5795	006	0		29	10	S5795_006_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	6.00	15.00								6.00		6.00	15.00								6.00			
S5795	006	0		29	10	S5795_006_0	3	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	25	25								25		25	25								25	Specialty																								
S5803	070	0		29	10	S5803_070_0	4	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	070	0		29	10	S5803_070_0	4	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	070	0		29	10	S5803_070_0	4	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	70	70								70											70	Non-Preferred Brand																								
S5803	071	0		29	10	S5803_071_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	071	0		29	10	S5803_071_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	071	0		29	10	S5803_071_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	072	0		29	10	S5803_072_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	072	0		29	10	S5803_072_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																								
S5803	072	0		29	10	S5803_072_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	073	0		29	10	S5803_073_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	70	70								70											70	Non-Preferred Brand																								
S5803	073	0		29	10	S5803_073_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	073	0		29	10	S5803_073_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	074	0		29	10	S5803_074_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	074	0		29	10	S5803_074_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	074	0		29	10	S5803_074_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	075	0		29	10	S5803_075_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	075	0		29	10	S5803_075_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	075	0		29	10	S5803_075_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	076	0		29	10	S5803_076_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	076	0		29	10	S5803_076_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	076	0		29	10	S5803_076_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	077	0		29	10	S5803_077_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	077	0		29	10	S5803_077_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	077	0		29	10	S5803_077_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	078	0		29	10	S5803_078_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	078	0		29	10	S5803_078_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	078	0		29	10	S5803_078_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	079	0		29	10	S5803_079_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	079	0		29	10	S5803_079_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	079	0		29	10	S5803_079_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	080	0		29	10	S5803_080_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	080	0		29	10	S5803_080_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	080	0		29	10	S5803_080_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	081	0		29	10	S5803_081_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	081	0		29	10	S5803_081_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	081	0		29	10	S5803_081_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	082	0		29	10	S5803_082_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	082	0		29	10	S5803_082_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	082	0		29	10	S5803_082_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	083	0		29	10	S5803_083_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	083	0		29	10	S5803_083_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	083	0		29	10	S5803_083_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	084	0		29	10	S5803_084_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	084	0		29	10	S5803_084_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	084	0		29	10	S5803_084_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	085	0		29	10	S5803_085_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	085	0		29	10	S5803_085_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	085	0		29	10	S5803_085_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	086	0		29	10	S5803_086_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	086	0		29	10	S5803_086_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	086	0		29	10	S5803_086_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	087	0		29	10	S5803_087_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	087	0		29	10	S5803_087_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	087	0		29	10	S5803_087_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	088	0		29	10	S5803_088_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	088	0		29	10	S5803_088_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	088	0		29	10	S5803_088_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	089	0		29	10	S5803_089_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	089	0		29	10	S5803_089_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	089	0		29	10	S5803_089_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	090	0		29	10	S5803_090_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	090	0		29	10	S5803_090_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	090	0		29	10	S5803_090_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	091	0		29	10	S5803_091_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	091	0		29	10	S5803_091_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	70	70								70											70	Non-Preferred Brand																								
S5803	091	0		29	10	S5803_091_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	092	0		29	10	S5803_092_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	092	0		29	10	S5803_092_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	092	0		29	10	S5803_092_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	093	0		29	10	S5803_093_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	093	0		29	10	S5803_093_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	093	0		29	10	S5803_093_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	094	0		29	10	S5803_094_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	094	0		29	10	S5803_094_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	60	60								60											60	Non-Preferred Brand																								
S5803	094	0		29	10	S5803_094_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	095	0		29	10	S5803_095_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	095	0		29	10	S5803_095_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	095	0		29	10	S5803_095_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	096	0		29	10	S5803_096_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	096	0		29	10	S5803_096_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	096	0		29	10	S5803_096_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	097	0		29	10	S5803_097_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	097	0		29	10	S5803_097_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	70	70								70											70	Non-Preferred Brand																								
S5803	097	0		29	10	S5803_097_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	098	0		29	10	S5803_098_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	70	70								70											70	Non-Preferred Brand																								
S5803	098	0		29	10	S5803_098_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	098	0		29	10	S5803_098_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	099	0		29	10	S5803_099_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	099	0		29	10	S5803_099_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	099	0		29	10	S5803_099_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	100	0		29	10	S5803_100_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50											50	Non-Preferred Brand																								
S5803	100	0		29	10	S5803_100_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	100	0		29	10	S5803_100_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	101	0		29	10	S5803_101_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75											75	Non-Preferred Brand																								
S5803	101	0		29	10	S5803_101_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	101	0		29	10	S5803_101_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	102	0		29	10	S5803_102_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	102	0		29	10	S5803_102_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	70	70								70											70	Non-Preferred Brand																								
S5803	102	0		29	10	S5803_102_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	103	0		29	10	S5803_103_0	3	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	103	0		29	10	S5803_103_0	3	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	65	65								65											65	Non-Preferred Brand																								
S5803	103	0		29	10	S5803_103_0	3	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	25	25								25											25	Preferred Brand																								
S5803	138	0		29	10	S5803_138_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	138	0		29	10	S5803_138_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	138	0		29	10	S5803_138_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	138	0		29	10	S5803_138_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	139	0		29	10	S5803_139_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	139	0		29	10	S5803_139_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	139	0		29	10	S5803_139_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	139	0		29	10	S5803_139_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	140	0		29	10	S5803_140_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	140	0		29	10	S5803_140_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	140	0		29	10	S5803_140_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	140	0		29	10	S5803_140_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	141	0		29	10	S5803_141_0	7	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	141	0		29	10	S5803_141_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	141	0		29	10	S5803_141_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	141	0		29	10	S5803_141_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	142	0		29	10	S5803_142_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	142	0		29	10	S5803_142_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	142	0		29	10	S5803_142_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	142	0		29	10	S5803_142_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	143	0		29	10	S5803_143_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	143	0		29	10	S5803_143_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	143	0		29	10	S5803_143_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	143	0		29	10	S5803_143_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	144	0		29	10	S5803_144_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	144	0		29	10	S5803_144_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	144	0		29	10	S5803_144_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	144	0		29	10	S5803_144_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	145	0		29	10	S5803_145_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	145	0		29	10	S5803_145_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	145	0		29	10	S5803_145_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	145	0		29	10	S5803_145_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	146	0		29	10	S5803_146_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	146	0		29	10	S5803_146_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	146	0		29	10	S5803_146_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	146	0		29	10	S5803_146_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	147	0		29	10	S5803_147_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	147	0		29	10	S5803_147_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	147	0		29	10	S5803_147_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	147	0		29	10	S5803_147_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	148	0		29	10	S5803_148_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	148	0		29	10	S5803_148_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	148	0		29	10	S5803_148_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	148	0		29	10	S5803_148_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	149	0		29	10	S5803_149_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	149	0		29	10	S5803_149_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	149	0		29	10	S5803_149_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	149	0		29	10	S5803_149_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	150	0		29	10	S5803_150_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	150	0		29	10	S5803_150_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	150	0		29	10	S5803_150_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	150	0		29	10	S5803_150_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	151	0		29	10	S5803_151_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	151	0		29	10	S5803_151_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	151	0		29	10	S5803_151_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	151	0		29	10	S5803_151_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	152	0		29	10	S5803_152_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	152	0		29	10	S5803_152_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	152	0		29	10	S5803_152_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	152	0		29	10	S5803_152_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	153	0		29	10	S5803_153_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	153	0		29	10	S5803_153_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	153	0		29	10	S5803_153_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	153	0		29	10	S5803_153_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	154	0		29	10	S5803_154_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	154	0		29	10	S5803_154_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	154	0		29	10	S5803_154_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	154	0		29	10	S5803_154_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	155	0		29	10	S5803_155_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	155	0		29	10	S5803_155_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	155	0		29	10	S5803_155_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	155	0		29	10	S5803_155_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	156	0		29	10	S5803_156_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	156	0		29	10	S5803_156_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	156	0		29	10	S5803_156_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	156	0		29	10	S5803_156_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	157	0		29	10	S5803_157_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	157	0		29	10	S5803_157_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	157	0		29	10	S5803_157_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	157	0		29	10	S5803_157_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	158	0		29	10	S5803_158_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	158	0		29	10	S5803_158_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	158	0		29	10	S5803_158_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	158	0		29	10	S5803_158_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	159	0		29	10	S5803_159_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	159	0		29	10	S5803_159_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	159	0		29	10	S5803_159_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	159	0		29	10	S5803_159_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	160	0		29	10	S5803_160_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	160	0		29	10	S5803_160_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	160	0		29	10	S5803_160_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	160	0		29	10	S5803_160_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	161	0		29	10	S5803_161_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	161	0		29	10	S5803_161_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	161	0		29	10	S5803_161_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	161	0		29	10	S5803_161_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	162	0		29	10	S5803_162_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	162	0		29	10	S5803_162_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	162	0		29	10	S5803_162_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	162	0		29	10	S5803_162_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	163	0		29	10	S5803_163_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	163	0		29	10	S5803_163_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	163	0		29	10	S5803_163_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	163	0		29	10	S5803_163_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	164	0		29	10	S5803_164_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	164	0		29	10	S5803_164_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	164	0		29	10	S5803_164_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	164	0		29	10	S5803_164_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	165	0		29	10	S5803_165_0	7	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	165	0		29	10	S5803_165_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	165	0		29	10	S5803_165_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	165	0		29	10	S5803_165_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	166	0		29	10	S5803_166_0	7	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	166	0		29	10	S5803_166_0	7	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	166	0		29	10	S5803_166_0	7	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	166	0		29	10	S5803_166_0	7	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	167	0		29	10	S5803_167_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	167	0		29	10	S5803_167_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	167	0		29	10	S5803_167_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	167	0		29	10	S5803_167_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	168	0		29	10	S5803_168_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	168	0		29	10	S5803_168_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	168	0		29	10	S5803_168_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	168	0		29	10	S5803_168_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	169	0		29	10	S5803_169_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	169	0		29	10	S5803_169_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	169	0		29	10	S5803_169_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	169	0		29	10	S5803_169_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	170	0		29	10	S5803_170_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	170	0		29	10	S5803_170_0	5	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	170	0		29	10	S5803_170_0	5	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	170	0		29	10	S5803_170_0	5	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	171	0		29	10	S5803_171_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	171	0		29	10	S5803_171_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	171	0		29	10	S5803_171_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	171	0		29	10	S5803_171_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	210	0		29	10	S5803_210_0	4	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	210	0		29	10	S5803_210_0	4	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	210	0		29	10	S5803_210_0	4	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	211	0		29	10	S5803_211_0	6	1	2	1	Generic	010000		2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	0.00	0.00								0.00											0.00			
S5803	211	0		29	10	S5803_211_0	6	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	1	Preferred Brand	30	30								30											30	Preferred Brand																								
S5803	211	0		29	10	S5803_211_0	6	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	1	Non-Preferred Brand	55	55								55											55	Non-Preferred Brand																								
S5803	214	0		29	10	S5803_214_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	214	0		29	10	S5803_214_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	214	0		29	10	S5803_214_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	214	0		29	10	S5803_214_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	215	0		29	10	S5803_215_0	6	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	29	29								29											29	Specialty																								
S5803	215	0		29	10	S5803_215_0	6	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	215	0		29	10	S5803_215_0	6	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	215	0		29	10	S5803_215_0	6	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	5.00	15.00								5.00											5.00			
S5803	218	0		29	10	S5803_218_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	218	0		29	10	S5803_218_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	218	0		29	10	S5803_218_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	218	0		29	10	S5803_218_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	218	0		29	10	S5803_218_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	218	0		29	10	S5803_218_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	218	0		29	10	S5803_218_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	218	0		29	10	S5803_218_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	219	0		29	10	S5803_219_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	219	0		29	10	S5803_219_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	219	0		29	10	S5803_219_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	219	0		29	10	S5803_219_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	219	0		29	10	S5803_219_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	219	0		29	10	S5803_219_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	219	0		29	10	S5803_219_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	219	0		29	10	S5803_219_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	221	0		29	10	S5803_221_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	221	0		29	10	S5803_221_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	221	0		29	10	S5803_221_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	221	0		29	10	S5803_221_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	221	0		29	10	S5803_221_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	221	0		29	10	S5803_221_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	221	0		29	10	S5803_221_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	221	0		29	10	S5803_221_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	222	0		29	10	S5803_222_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	222	0		29	10	S5803_222_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	222	0		29	10	S5803_222_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	222	0		29	10	S5803_222_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	222	0		29	10	S5803_222_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	222	0		29	10	S5803_222_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	222	0		29	10	S5803_222_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	222	0		29	10	S5803_222_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	223	0		29	10	S5803_223_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	223	0		29	10	S5803_223_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	223	0		29	10	S5803_223_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	223	0		29	10	S5803_223_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	223	0		29	10	S5803_223_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	223	0		29	10	S5803_223_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	223	0		29	10	S5803_223_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	223	0		29	10	S5803_223_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	224	0		29	10	S5803_224_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	224	0		29	10	S5803_224_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	224	0		29	10	S5803_224_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	224	0		29	10	S5803_224_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	224	0		29	10	S5803_224_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	224	0		29	10	S5803_224_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	224	0		29	10	S5803_224_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	224	0		29	10	S5803_224_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	225	0		29	10	S5803_225_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	225	0		29	10	S5803_225_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	225	0		29	10	S5803_225_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	225	0		29	10	S5803_225_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	225	0		29	10	S5803_225_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	225	0		29	10	S5803_225_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	225	0		29	10	S5803_225_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	225	0		29	10	S5803_225_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	226	0		29	10	S5803_226_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	226	0		29	10	S5803_226_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	226	0		29	10	S5803_226_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	226	0		29	10	S5803_226_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	226	0		29	10	S5803_226_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	226	0		29	10	S5803_226_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	226	0		29	10	S5803_226_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	226	0		29	10	S5803_226_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	227	0		29	10	S5803_227_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	227	0		29	10	S5803_227_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	227	0		29	10	S5803_227_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	227	0		29	10	S5803_227_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	227	0		29	10	S5803_227_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	227	0		29	10	S5803_227_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	227	0		29	10	S5803_227_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	227	0		29	10	S5803_227_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	228	0		29	10	S5803_228_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	228	0		29	10	S5803_228_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	228	0		29	10	S5803_228_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	228	0		29	10	S5803_228_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	228	0		29	10	S5803_228_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	228	0		29	10	S5803_228_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	228	0		29	10	S5803_228_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	228	0		29	10	S5803_228_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	229	0		29	10	S5803_229_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	229	0		29	10	S5803_229_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	229	0		29	10	S5803_229_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	229	0		29	10	S5803_229_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	229	0		29	10	S5803_229_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	229	0		29	10	S5803_229_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	229	0		29	10	S5803_229_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	229	0		29	10	S5803_229_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	230	0		29	10	S5803_230_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	230	0		29	10	S5803_230_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	230	0		29	10	S5803_230_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	230	0		29	10	S5803_230_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	230	0		29	10	S5803_230_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	230	0		29	10	S5803_230_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	230	0		29	10	S5803_230_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	230	0		29	10	S5803_230_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	231	0		29	10	S5803_231_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	231	0		29	10	S5803_231_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	231	0		29	10	S5803_231_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	231	0		29	10	S5803_231_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	231	0		29	10	S5803_231_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	231	0		29	10	S5803_231_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	231	0		29	10	S5803_231_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	231	0		29	10	S5803_231_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	232	0		29	10	S5803_232_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	232	0		29	10	S5803_232_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	232	0		29	10	S5803_232_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	232	0		29	10	S5803_232_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	232	0		29	10	S5803_232_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	232	0		29	10	S5803_232_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	232	0		29	10	S5803_232_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	232	0		29	10	S5803_232_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	233	0		29	10	S5803_233_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	233	0		29	10	S5803_233_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	233	0		29	10	S5803_233_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	233	0		29	10	S5803_233_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	233	0		29	10	S5803_233_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	233	0		29	10	S5803_233_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	233	0		29	10	S5803_233_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	233	0		29	10	S5803_233_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	234	0		29	10	S5803_234_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	234	0		29	10	S5803_234_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	234	0		29	10	S5803_234_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	234	0		29	10	S5803_234_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	234	0		29	10	S5803_234_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	234	0		29	10	S5803_234_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	234	0		29	10	S5803_234_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	234	0		29	10	S5803_234_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	235	0		29	10	S5803_235_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	235	0		29	10	S5803_235_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	235	0		29	10	S5803_235_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	235	0		29	10	S5803_235_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	235	0		29	10	S5803_235_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	235	0		29	10	S5803_235_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	235	0		29	10	S5803_235_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	235	0		29	10	S5803_235_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	236	0		29	10	S5803_236_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	236	0		29	10	S5803_236_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	236	0		29	10	S5803_236_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	236	0		29	10	S5803_236_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	236	0		29	10	S5803_236_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	236	0		29	10	S5803_236_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	236	0		29	10	S5803_236_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	236	0		29	10	S5803_236_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	237	0		29	10	S5803_237_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	237	0		29	10	S5803_237_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	237	0		29	10	S5803_237_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	237	0		29	10	S5803_237_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	237	0		29	10	S5803_237_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	237	0		29	10	S5803_237_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	237	0		29	10	S5803_237_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	237	0		29	10	S5803_237_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	238	0		29	10	S5803_238_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	238	0		29	10	S5803_238_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	238	0		29	10	S5803_238_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	238	0		29	10	S5803_238_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	238	0		29	10	S5803_238_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	238	0		29	10	S5803_238_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	238	0		29	10	S5803_238_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	238	0		29	10	S5803_238_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	239	0		29	10	S5803_239_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	239	0		29	10	S5803_239_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	239	0		29	10	S5803_239_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	239	0		29	10	S5803_239_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	239	0		29	10	S5803_239_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	239	0		29	10	S5803_239_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	239	0		29	10	S5803_239_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	239	0		29	10	S5803_239_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	240	0		29	10	S5803_240_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	240	0		29	10	S5803_240_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	240	0		29	10	S5803_240_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	240	0		29	10	S5803_240_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	240	0		29	10	S5803_240_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	240	0		29	10	S5803_240_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	240	0		29	10	S5803_240_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	240	0		29	10	S5803_240_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	241	0		29	10	S5803_241_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	241	0		29	10	S5803_241_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	241	0		29	10	S5803_241_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	241	0		29	10	S5803_241_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	241	0		29	10	S5803_241_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	241	0		29	10	S5803_241_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	241	0		29	10	S5803_241_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	241	0		29	10	S5803_241_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	242	0		29	10	S5803_242_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	242	0		29	10	S5803_242_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	242	0		29	10	S5803_242_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	242	0		29	10	S5803_242_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	242	0		29	10	S5803_242_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	242	0		29	10	S5803_242_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	242	0		29	10	S5803_242_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	242	0		29	10	S5803_242_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	243	0		29	10	S5803_243_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	243	0		29	10	S5803_243_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	243	0		29	10	S5803_243_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	243	0		29	10	S5803_243_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	243	0		29	10	S5803_243_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	243	0		29	10	S5803_243_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	243	0		29	10	S5803_243_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	243	0		29	10	S5803_243_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	244	0		29	10	S5803_244_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	244	0		29	10	S5803_244_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	244	0		29	10	S5803_244_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	244	0		29	10	S5803_244_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	244	0		29	10	S5803_244_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	244	0		29	10	S5803_244_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	244	0		29	10	S5803_244_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	244	0		29	10	S5803_244_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	245	0		29	10	S5803_245_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	245	0		29	10	S5803_245_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	245	0		29	10	S5803_245_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	245	0		29	10	S5803_245_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	245	0		29	10	S5803_245_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	245	0		29	10	S5803_245_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	245	0		29	10	S5803_245_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	245	0		29	10	S5803_245_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	246	0		29	10	S5803_246_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	246	0		29	10	S5803_246_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	246	0		29	10	S5803_246_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	246	0		29	10	S5803_246_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	246	0		29	10	S5803_246_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	246	0		29	10	S5803_246_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	246	0		29	10	S5803_246_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	246	0		29	10	S5803_246_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	247	0		29	10	S5803_247_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	247	0		29	10	S5803_247_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	247	0		29	10	S5803_247_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	247	0		29	10	S5803_247_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	247	0		29	10	S5803_247_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	247	0		29	10	S5803_247_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	247	0		29	10	S5803_247_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	247	0		29	10	S5803_247_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	248	0		29	10	S5803_248_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	248	0		29	10	S5803_248_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	248	0		29	10	S5803_248_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	248	0		29	10	S5803_248_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	248	0		29	10	S5803_248_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	248	0		29	10	S5803_248_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	248	0		29	10	S5803_248_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	248	0		29	10	S5803_248_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	249	0		29	10	S5803_249_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	249	0		29	10	S5803_249_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	249	0		29	10	S5803_249_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	249	0		29	10	S5803_249_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	249	0		29	10	S5803_249_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	249	0		29	10	S5803_249_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	249	0		29	10	S5803_249_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	249	0		29	10	S5803_249_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	250	0		29	10	S5803_250_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	250	0		29	10	S5803_250_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	250	0		29	10	S5803_250_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	250	0		29	10	S5803_250_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	250	0		29	10	S5803_250_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	250	0		29	10	S5803_250_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	250	0		29	10	S5803_250_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	250	0		29	10	S5803_250_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	251	0		29	10	S5803_251_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	251	0		29	10	S5803_251_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	251	0		29	10	S5803_251_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	251	0		29	10	S5803_251_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	251	0		29	10	S5803_251_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	251	0		29	10	S5803_251_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	251	0		29	10	S5803_251_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	251	0		29	10	S5803_251_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	252	0		29	10	S5803_252_0	4	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	252	0		29	10	S5803_252_0	4	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5803	252	0		29	10	S5803_252_0	4	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	252	0		29	10	S5803_252_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	252	0		29	10	S5803_252_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	252	0		29	10	S5803_252_0	4	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	252	0		29	10	S5803_252_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	252	0		29	10	S5803_252_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	253	0		29	10	S5803_253_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5803	253	0		29	10	S5803_253_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5803	253	0		29	10	S5803_253_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5803	253	0		29	10	S5803_253_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5803	253	0		29	10	S5803_253_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5803	253	0		29	10	S5803_253_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5803	253	0		29	10	S5803_253_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5803	253	0		29	10	S5803_253_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5805	001	0		29	10	S5805_001_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5805	001	0		29	10	S5805_001_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5805	001	0		29	10	S5805_001_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	71.25	213.75								71.25						198.75			213.75		71.25			
S5805	001	0		29	10	S5805_001_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5810	035	0		29	10	S5810_035_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					192.00			207.00		69.00			
S5810	035	0		29	10	S5810_035_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	035	0		29	10	S5810_035_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	035	0		29	10	S5810_035_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					12.00			12.00		4.00			
S5810	035	0		29	10	S5810_035_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	036	0		29	10	S5810_036_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					12.00			12.00		4.00			
S5810	036	0		29	10	S5810_036_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	036	0		29	10	S5810_036_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					75.00			90.00		30.00			
S5810	036	0		29	10	S5810_036_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	72.00	216.00									72.00					201.00			216.00		72.00			
S5810	036	0		29	10	S5810_036_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	037	0		29	10	S5810_037_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					186.00			201.00		67.00			
S5810	037	0		29	10	S5810_037_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	25.00	75.00									25.00					60.00			75.00		25.00			
S5810	037	0		29	10	S5810_037_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	24.00	72.00									24.00					57.00			72.00		24.00			
S5810	037	0		29	10	S5810_037_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	037	0		29	10	S5810_037_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	038	0		29	10	S5810_038_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				24.00	60.00		24.00	72.00			24.00					57.00			72.00		24.00			
S5810	038	0		29	10	S5810_038_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				3.00	7.50		3.00	9.00			3.00					9.00			9.00		3.00			
S5810	038	0		29	10	S5810_038_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				25.00	62.50		25.00	75.00			25.00					60.00			75.00		25.00			
S5810	038	0		29	10	S5810_038_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				67.00	167.50		67.00	201.00			67.00					186.00			201.00		67.00			
S5810	038	0		29	10	S5810_038_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
S5810	039	0		29	10	S5810_039_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				26.00	65.00		26.00	78.00			26.00					63.00			78.00		26.00			
S5810	039	0		29	10	S5810_039_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				3.00	7.50		3.00	9.00			3.00					9.00			9.00		3.00			
S5810	039	0		29	10	S5810_039_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				27.00	67.50		27.00	81.00			27.00					66.00			81.00		27.00			
S5810	039	0		29	10	S5810_039_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	2	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
S5810	039	0		29	10	S5810_039_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				70.00	175.00		70.00	210.00			70.00					195.00			210.00		70.00			
S5810	040	0		29	10	S5810_040_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				3.00	7.50		3.00	9.00			3.00					9.00			9.00		3.00			
S5810	040	0		29	10	S5810_040_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				25.00	62.50		25.00	75.00			25.00					60.00			75.00		25.00			
S5810	040	0		29	10	S5810_040_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				68.00	170.00		68.00	204.00			68.00					189.00			204.00		68.00			
S5810	040	0		29	10	S5810_040_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				26.00	65.00		26.00	78.00			26.00					63.00			78.00		26.00			
S5810	040	0		29	10	S5810_040_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
S5810	041	0		29	10	S5810_041_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	041	0		29	10	S5810_041_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					60.00			75.00		25.00			
S5810	041	0		29	10	S5810_041_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	041	0		29	10	S5810_041_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	041	0		29	10	S5810_041_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	042	0		29	10	S5810_042_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	042	0		29	10	S5810_042_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	042	0		29	10	S5810_042_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					60.00			75.00		25.00			
S5810	042	0		29	10	S5810_042_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					192.00			207.00		69.00			
S5810	042	0		29	10	S5810_042_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	043	0		29	10	S5810_043_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	043	0		29	10	S5810_043_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	69.00	207.00									69.00					192.00			207.00		69.00			
S5810	043	0		29	10	S5810_043_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	043	0		29	10	S5810_043_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	043	0		29	10	S5810_043_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	044	0		29	10	S5810_044_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	044	0		29	10	S5810_044_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	044	0		29	10	S5810_044_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	044	0		29	10	S5810_044_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	044	0		29	10	S5810_044_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	045	0		29	10	S5810_045_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	045	0		29	10	S5810_045_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	4.00	12.00									4.00					12.00			12.00		4.00			
S5810	045	0		29	10	S5810_045_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	045	0		29	10	S5810_045_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	045	0		29	10	S5810_045_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					189.00			204.00		68.00			
S5810	046	0		29	10	S5810_046_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	046	0		29	10	S5810_046_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	046	0		29	10	S5810_046_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	046	0		29	10	S5810_046_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	046	0		29	10	S5810_046_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	047	0		29	10	S5810_047_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	047	0		29	10	S5810_047_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	047	0		29	10	S5810_047_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	047	0		29	10	S5810_047_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	047	0		29	10	S5810_047_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	048	0		29	10	S5810_048_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	2	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	048	0		29	10	S5810_048_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	048	0		29	10	S5810_048_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	048	0		29	10	S5810_048_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	67.00	201.00									67.00					186.00			201.00		67.00			
S5810	048	0		29	10	S5810_048_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	049	0		29	10	S5810_049_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	049	0		29	10	S5810_049_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	049	0		29	10	S5810_049_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	049	0		29	10	S5810_049_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	049	0		29	10	S5810_049_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	050	0		29	10	S5810_050_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	050	0		29	10	S5810_050_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	050	0		29	10	S5810_050_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	050	0		29	10	S5810_050_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	050	0		29	10	S5810_050_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	051	0		29	10	S5810_051_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	051	0		29	10	S5810_051_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	051	0		29	10	S5810_051_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	051	0		29	10	S5810_051_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	051	0		29	10	S5810_051_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	052	0		29	10	S5810_052_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	052	0		29	10	S5810_052_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	052	0		29	10	S5810_052_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	052	0		29	10	S5810_052_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	052	0		29	10	S5810_052_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	053	0		29	10	S5810_053_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	053	0		29	10	S5810_053_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	053	0		29	10	S5810_053_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	053	0		29	10	S5810_053_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	053	0		29	10	S5810_053_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	054	0		29	10	S5810_054_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	1.00	3.00									1.00					3.00			3.00		1.00			
S5810	054	0		29	10	S5810_054_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	054	0		29	10	S5810_054_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	23.00	69.00									23.00					54.00			69.00		23.00			
S5810	054	0		29	10	S5810_054_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	24.00	72.00									24.00					57.00			72.00		24.00			
S5810	054	0		29	10	S5810_054_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	68.00	204.00									68.00					189.00			204.00		68.00			
S5810	055	0		29	10	S5810_055_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	055	0		29	10	S5810_055_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	055	0		29	10	S5810_055_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	055	0		29	10	S5810_055_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	055	0		29	10	S5810_055_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	25.00	75.00									25.00					60.00			75.00		25.00			
S5810	056	0		29	10	S5810_056_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				1.00	2.50		1.00	3.00			1.00					3.00			3.00		1.00			
S5810	056	0		29	10	S5810_056_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				25	25		25	25			25					25			25		25	Tier 5 - Specialty																								
S5810	056	0		29	10	S5810_056_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				24.00	60.00		24.00	72.00			24.00					57.00			72.00		24.00			
S5810	056	0		29	10	S5810_056_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				29.00	72.50		29.00	87.00			29.00					72.00			87.00		29.00			
S5810	056	0		29	10	S5810_056_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				69.00	172.50		69.00	207.00			69.00					192.00			207.00		69.00			
S5810	057	0		29	10	S5810_057_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	057	0		29	10	S5810_057_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	057	0		29	10	S5810_057_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	72.00	216.00									72.00					201.00			216.00		72.00			
S5810	057	0		29	10	S5810_057_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	057	0		29	10	S5810_057_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	058	0		29	10	S5810_058_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	058	0		29	10	S5810_058_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	058	0		29	10	S5810_058_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	058	0		29	10	S5810_058_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	058	0		29	10	S5810_058_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	059	0		29	10	S5810_059_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	059	0		29	10	S5810_059_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					75.00			90.00		30.00			
S5810	059	0		29	10	S5810_059_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	059	0		29	10	S5810_059_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	059	0		29	10	S5810_059_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	060	0		29	10	S5810_060_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	26.00	78.00									26.00					63.00			78.00		26.00			
S5810	060	0		29	10	S5810_060_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	060	0		29	10	S5810_060_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	060	0		29	10	S5810_060_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	060	0		29	10	S5810_060_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	061	0		29	10	S5810_061_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	061	0		29	10	S5810_061_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	061	0		29	10	S5810_061_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	061	0		29	10	S5810_061_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	27.00	81.00									27.00					66.00			81.00		27.00			
S5810	061	0		29	10	S5810_061_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	062	0		29	10	S5810_062_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	062	0		29	10	S5810_062_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	062	0		29	10	S5810_062_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	062	0		29	10	S5810_062_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	062	0		29	10	S5810_062_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	063	0		29	10	S5810_063_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	063	0		29	10	S5810_063_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	063	0		29	10	S5810_063_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					75.00			90.00		30.00			
S5810	063	0		29	10	S5810_063_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	063	0		29	10	S5810_063_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	064	0		29	10	S5810_064_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	064	0		29	10	S5810_064_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	064	0		29	10	S5810_064_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					75.00			90.00		30.00			
S5810	064	0		29	10	S5810_064_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	064	0		29	10	S5810_064_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	065	0		29	10	S5810_065_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	065	0		29	10	S5810_065_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					75.00			90.00		30.00			
S5810	065	0		29	10	S5810_065_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	065	0		29	10	S5810_065_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	065	0		29	10	S5810_065_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	066	0		29	10	S5810_066_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	066	0		29	10	S5810_066_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	066	0		29	10	S5810_066_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	066	0		29	10	S5810_066_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	066	0		29	10	S5810_066_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	067	0		29	10	S5810_067_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	2.00	6.00									2.00					6.00			6.00		2.00			
S5810	067	0		29	10	S5810_067_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	28.00	84.00									28.00					69.00			84.00		28.00			
S5810	067	0		29	10	S5810_067_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	067	0		29	10	S5810_067_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	70.00	210.00									70.00					195.00			210.00		70.00			
S5810	067	0		29	10	S5810_067_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	068	0		29	10	S5810_068_0	2	1	2	1	Tier 1 - Preferred Generic	001000		2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	3.00	9.00									3.00					9.00			9.00		3.00			
S5810	068	0		29	10	S5810_068_0	2	2	2	1	Tier 2 - Non-Preferred Generic	000100		2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	068	0		29	10	S5810_068_0	2	3	2	1	Tier 3 - Preferred Brand	000001		2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	30.00	90.00									30.00					75.00			90.00		30.00			
S5810	068	0		29	10	S5810_068_0	2	4	2	1	Tier 4 - Non-Preferred Brand	100000		2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	72.00	216.00									72.00					201.00			216.00		72.00			
S5810	068	0		29	10	S5810_068_0	2	5	2	1	Tier 5 - Specialty	010010		1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	25	25									25					25			25		25	Tier 5 - Specialty																								
S5810	171	0		29	10	S5810_171_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	171	0		29	10	S5810_171_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	171	0		29	10	S5810_171_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	171	0		29	10	S5810_171_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	81.00	243.00									81.00					228.00			243.00		81.00			
S5810	171	0		29	10	S5810_171_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	171	0		29	10	S5810_171_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	171	0		29	10	S5810_171_0	4	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																						2		
S5810	171	0		29	10	S5810_171_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																						2		
S5810	171	0		29	10	S5810_171_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	171	0		29	10	S5810_171_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	172	0		29	10	S5810_172_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	172	0		29	10	S5810_172_0	4	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																						2		
S5810	172	0		29	10	S5810_172_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																						2		
S5810	172	0		29	10	S5810_172_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	172	0		29	10	S5810_172_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	172	0		29	10	S5810_172_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	172	0		29	10	S5810_172_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	172	0		29	10	S5810_172_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	172	0		29	10	S5810_172_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	87.00	261.00									87.00					246.00			261.00		87.00			
S5810	172	0		29	10	S5810_172_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	173	0		29	10	S5810_173_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	8.00	24.00									8.00					24.00			24.00		8.00			
S5810	173	0		29	10	S5810_173_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	173	0		29	10	S5810_173_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	173	0		29	10	S5810_173_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	88.00	264.00									88.00					249.00			264.00		88.00			
S5810	173	0		29	10	S5810_173_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	173	0		29	10	S5810_173_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	173	0		29	10	S5810_173_0	4	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																						2		
S5810	173	0		29	10	S5810_173_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																						2		
S5810	173	0		29	10	S5810_173_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	173	0		29	10	S5810_173_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	174	0		29	10	S5810_174_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				6.00	15.00		6.00	18.00			6.00					18.00			18.00		6.00			
S5810	174	0		29	10	S5810_174_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				37.00	92.50		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	174	0		29	10	S5810_174_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	174	0		29	10	S5810_174_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				82.00	205.00		82.00	246.00			82.00					231.00			246.00		82.00			
S5810	174	0		29	10	S5810_174_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	174	0		29	10	S5810_174_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				16.00	40.00		16.00	48.00			16.00					48.00			48.00		16.00	1	1	
S5810	174	0		29	10	S5810_174_0	4	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																						2		
S5810	174	0		29	10	S5810_174_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																						2		
S5810	174	0		29	10	S5810_174_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	174	0		29	10	S5810_174_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	175	0		29	10	S5810_175_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	175	0		29	10	S5810_175_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				84.00	210.00		84.00	252.00			84.00					237.00			252.00		84.00			
S5810	175	0		29	10	S5810_175_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	175	0		29	10	S5810_175_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				16.00	40.00		16.00	48.00			16.00					48.00			48.00		16.00	1	1	
S5810	175	0		29	10	S5810_175_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				37.00	92.50		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	175	0		29	10	S5810_175_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																						2		
S5810	175	0		29	10	S5810_175_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	175	0		29	10	S5810_175_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	175	0		29	10	S5810_175_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				6.00	15.00		6.00	18.00			6.00					18.00			18.00		6.00			
S5810	175	0		29	10	S5810_175_0	4	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																						2		
S5810	176	0		29	10	S5810_176_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				7.00	17.50		7.00	21.00			7.00					21.00			21.00		7.00			
S5810	176	0		29	10	S5810_176_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				33.00	82.50		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	176	0		29	10	S5810_176_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				36.00	90.00		36.00	108.00			36.00					93.00			108.00		36.00			
S5810	176	0		29	10	S5810_176_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				86.00	215.00		86.00	258.00			86.00					243.00			258.00		86.00			
S5810	176	0		29	10	S5810_176_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	176	0		29	10	S5810_176_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				16.00	40.00		16.00	48.00			16.00					48.00			48.00		16.00	1	1	
S5810	176	0		29	10	S5810_176_0	4	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																						2		
S5810	176	0		29	10	S5810_176_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																						2		
S5810	176	0		29	10	S5810_176_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	176	0		29	10	S5810_176_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	177	0		29	10	S5810_177_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	86.00	258.00									86.00					243.00			258.00		86.00			
S5810	177	0		29	10	S5810_177_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	177	0		29	10	S5810_177_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	177	0		29	10	S5810_177_0	4	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																						2		
S5810	177	0		29	10	S5810_177_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	177	0		29	10	S5810_177_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	177	0		29	10	S5810_177_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	177	0		29	10	S5810_177_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	177	0		29	10	S5810_177_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	177	0		29	10	S5810_177_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																						2		
S5810	178	0		29	10	S5810_178_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	178	0		29	10	S5810_178_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	34.00	102.00									34.00					87.00			102.00		34.00			
S5810	178	0		29	10	S5810_178_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	178	0		29	10	S5810_178_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	83.00	249.00									83.00					234.00			249.00		83.00			
S5810	178	0		29	10	S5810_178_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	178	0		29	10	S5810_178_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	178	0		29	10	S5810_178_0	4	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																						2		
S5810	178	0		29	10	S5810_178_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																						2		
S5810	178	0		29	10	S5810_178_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	178	0		29	10	S5810_178_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	179	0		29	10	S5810_179_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	179	0		29	10	S5810_179_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	179	0		29	10	S5810_179_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	179	0		29	10	S5810_179_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	84.00	252.00									84.00					237.00			252.00		84.00			
S5810	179	0		29	10	S5810_179_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	179	0		29	10	S5810_179_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	179	0		29	10	S5810_179_0	4	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																						2		
S5810	179	0		29	10	S5810_179_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																						2		
S5810	179	0		29	10	S5810_179_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	179	0		29	10	S5810_179_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	180	0		29	10	S5810_180_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	180	0		29	10	S5810_180_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	180	0		29	10	S5810_180_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	33.00	99.00									33.00					84.00			99.00		33.00			
S5810	180	0		29	10	S5810_180_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	180	0		29	10	S5810_180_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																						2		
S5810	180	0		29	10	S5810_180_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	180	0		29	10	S5810_180_0	4	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																						2		
S5810	180	0		29	10	S5810_180_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	180	0		29	10	S5810_180_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	180	0		29	10	S5810_180_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	181	0		29	10	S5810_181_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	181	0		29	10	S5810_181_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	181	0		29	10	S5810_181_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																						2		
S5810	181	0		29	10	S5810_181_0	4	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																						2		
S5810	181	0		29	10	S5810_181_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	181	0		29	10	S5810_181_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	181	0		29	10	S5810_181_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	85.00	255.00									85.00					240.00			255.00		85.00			
S5810	181	0		29	10	S5810_181_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	181	0		29	10	S5810_181_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	181	0		29	10	S5810_181_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	182	0		29	10	S5810_182_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	182	0		29	10	S5810_182_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	182	0		29	10	S5810_182_0	4	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																						2		
S5810	182	0		29	10	S5810_182_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																						2		
S5810	182	0		29	10	S5810_182_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	84.00	252.00									84.00					237.00			252.00		84.00			
S5810	182	0		29	10	S5810_182_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	182	0		29	10	S5810_182_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	182	0		29	10	S5810_182_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	182	0		29	10	S5810_182_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	182	0		29	10	S5810_182_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	183	0		29	10	S5810_183_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	183	0		29	10	S5810_183_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	183	0		29	10	S5810_183_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																						2		
S5810	183	0		29	10	S5810_183_0	4	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																						2		
S5810	183	0		29	10	S5810_183_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	183	0		29	10	S5810_183_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	183	0		29	10	S5810_183_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	183	0		29	10	S5810_183_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	82.00	246.00									82.00					231.00			246.00		82.00			
S5810	183	0		29	10	S5810_183_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	183	0		29	10	S5810_183_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	184	0		29	10	S5810_184_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	184	0		29	10	S5810_184_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	184	0		29	10	S5810_184_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	184	0		29	10	S5810_184_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																						2		
S5810	184	0		29	10	S5810_184_0	4	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																						2		
S5810	184	0		29	10	S5810_184_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	184	0		29	10	S5810_184_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	184	0		29	10	S5810_184_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	184	0		29	10	S5810_184_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	184	0		29	10	S5810_184_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	185	0		29	10	S5810_185_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	185	0		29	10	S5810_185_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	185	0		29	10	S5810_185_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	185	0		29	10	S5810_185_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	185	0		29	10	S5810_185_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	185	0		29	10	S5810_185_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	185	0		29	10	S5810_185_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	185	0		29	10	S5810_185_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	185	0		29	10	S5810_185_0	4	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																						2		
S5810	185	0		29	10	S5810_185_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																						2		
S5810	186	0		29	10	S5810_186_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	186	0		29	10	S5810_186_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	83.00	249.00									83.00					234.00			249.00		83.00			
S5810	186	0		29	10	S5810_186_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	186	0		29	10	S5810_186_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	186	0		29	10	S5810_186_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	186	0		29	10	S5810_186_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																						2		
S5810	186	0		29	10	S5810_186_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	186	0		29	10	S5810_186_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	186	0		29	10	S5810_186_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	186	0		29	10	S5810_186_0	4	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																						2		
S5810	187	0		29	10	S5810_187_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	187	0		29	10	S5810_187_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	187	0		29	10	S5810_187_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																						2		
S5810	187	0		29	10	S5810_187_0	4	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																						2		
S5810	187	0		29	10	S5810_187_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	187	0		29	10	S5810_187_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	187	0		29	10	S5810_187_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	84.00	252.00									84.00					237.00			252.00		84.00			
S5810	187	0		29	10	S5810_187_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	187	0		29	10	S5810_187_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	187	0		29	10	S5810_187_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	188	0		29	10	S5810_188_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	188	0		29	10	S5810_188_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	34.00	102.00									34.00					87.00			102.00		34.00			
S5810	188	0		29	10	S5810_188_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	188	0		29	10	S5810_188_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	82.00	246.00									82.00					231.00			246.00		82.00			
S5810	188	0		29	10	S5810_188_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	188	0		29	10	S5810_188_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	188	0		29	10	S5810_188_0	4	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																						2		
S5810	188	0		29	10	S5810_188_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																						2		
S5810	188	0		29	10	S5810_188_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	188	0		29	10	S5810_188_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	189	0		29	10	S5810_189_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	189	0		29	10	S5810_189_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	189	0		29	10	S5810_189_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																						2		
S5810	189	0		29	10	S5810_189_0	4	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																						2		
S5810	189	0		29	10	S5810_189_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	189	0		29	10	S5810_189_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	189	0		29	10	S5810_189_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	88.00	264.00									88.00					249.00			264.00		88.00			
S5810	189	0		29	10	S5810_189_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	189	0		29	10	S5810_189_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	189	0		29	10	S5810_189_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	190	0		29	10	S5810_190_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	190	0		29	10	S5810_190_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	190	0		29	10	S5810_190_0	4	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																						2		
S5810	190	0		29	10	S5810_190_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																						2		
S5810	190	0		29	10	S5810_190_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	81.00	243.00									81.00					228.00			243.00		81.00			
S5810	190	0		29	10	S5810_190_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	190	0		29	10	S5810_190_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	190	0		29	10	S5810_190_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	33.00	99.00									33.00					84.00			99.00		33.00			
S5810	190	0		29	10	S5810_190_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					87.00			102.00		34.00			
S5810	190	0		29	10	S5810_190_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	191	0		29	10	S5810_191_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	191	0		29	10	S5810_191_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	33.00	99.00									33.00					84.00			99.00		33.00			
S5810	191	0		29	10	S5810_191_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					87.00			102.00		34.00			
S5810	191	0		29	10	S5810_191_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	191	0		29	10	S5810_191_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	191	0		29	10	S5810_191_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	191	0		29	10	S5810_191_0	4	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																						2		
S5810	191	0		29	10	S5810_191_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																						2		
S5810	191	0		29	10	S5810_191_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	191	0		29	10	S5810_191_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	192	0		29	10	S5810_192_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					15.00			15.00		5.00			
S5810	192	0		29	10	S5810_192_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				34.00	85.00		34.00	102.00			34.00					87.00			102.00		34.00			
S5810	192	0		29	10	S5810_192_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					90.00			105.00		35.00			
S5810	192	0		29	10	S5810_192_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				81.00	202.50		81.00	243.00			81.00					228.00			243.00		81.00			
S5810	192	0		29	10	S5810_192_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	192	0		29	10	S5810_192_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				16.00	40.00		16.00	48.00			16.00					48.00			48.00		16.00	1	1	
S5810	192	0		29	10	S5810_192_0	4	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																						2		
S5810	192	0		29	10	S5810_192_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																						2		
S5810	192	0		29	10	S5810_192_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	192	0		29	10	S5810_192_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	193	0		29	10	S5810_193_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	193	0		29	10	S5810_193_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	193	0		29	10	S5810_193_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	193	0		29	10	S5810_193_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	193	0		29	10	S5810_193_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	193	0		29	10	S5810_193_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	193	0		29	10	S5810_193_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	193	0		29	10	S5810_193_0	4	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																						2		
S5810	193	0		29	10	S5810_193_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																						2		
S5810	193	0		29	10	S5810_193_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	194	0		29	10	S5810_194_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	194	0		29	10	S5810_194_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	194	0		29	10	S5810_194_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	194	0		29	10	S5810_194_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	194	0		29	10	S5810_194_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																						2		
S5810	194	0		29	10	S5810_194_0	4	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																						2		
S5810	194	0		29	10	S5810_194_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	194	0		29	10	S5810_194_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	29.00	87.00									29.00					72.00			87.00		29.00			
S5810	194	0		29	10	S5810_194_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	194	0		29	10	S5810_194_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	78.00	234.00									78.00					219.00			234.00		78.00			
S5810	195	0		29	10	S5810_195_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	195	0		29	10	S5810_195_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	195	0		29	10	S5810_195_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	195	0		29	10	S5810_195_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	81.00	243.00									81.00					228.00			243.00		81.00			
S5810	195	0		29	10	S5810_195_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	195	0		29	10	S5810_195_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	195	0		29	10	S5810_195_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																						2		
S5810	195	0		29	10	S5810_195_0	4	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																						2		
S5810	195	0		29	10	S5810_195_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	195	0		29	10	S5810_195_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	196	0		29	10	S5810_196_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	196	0		29	10	S5810_196_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																						2		
S5810	196	0		29	10	S5810_196_0	4	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																						2		
S5810	196	0		29	10	S5810_196_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	196	0		29	10	S5810_196_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	196	0		29	10	S5810_196_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	82.00	246.00									82.00					231.00			246.00		82.00			
S5810	196	0		29	10	S5810_196_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	196	0		29	10	S5810_196_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	196	0		29	10	S5810_196_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	196	0		29	10	S5810_196_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	197	0		29	10	S5810_197_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	197	0		29	10	S5810_197_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	84.00	252.00									84.00					237.00			252.00		84.00			
S5810	197	0		29	10	S5810_197_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	197	0		29	10	S5810_197_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	197	0		29	10	S5810_197_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	197	0		29	10	S5810_197_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	197	0		29	10	S5810_197_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																						2		
S5810	197	0		29	10	S5810_197_0	4	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																						2		
S5810	197	0		29	10	S5810_197_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	197	0		29	10	S5810_197_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	198	0		29	10	S5810_198_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	198	0		29	10	S5810_198_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	198	0		29	10	S5810_198_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																						2		
S5810	198	0		29	10	S5810_198_0	4	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																						2		
S5810	198	0		29	10	S5810_198_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	198	0		29	10	S5810_198_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	82.00	246.00									82.00					231.00			246.00		82.00			
S5810	198	0		29	10	S5810_198_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	198	0		29	10	S5810_198_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	198	0		29	10	S5810_198_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	6.00	18.00									6.00					18.00			18.00		6.00			
S5810	198	0		29	10	S5810_198_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	199	0		29	10	S5810_199_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	199	0		29	10	S5810_199_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	199	0		29	10	S5810_199_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	199	0		29	10	S5810_199_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	88.00	264.00									88.00					249.00			264.00		88.00			
S5810	199	0		29	10	S5810_199_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	199	0		29	10	S5810_199_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	199	0		29	10	S5810_199_0	4	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																						2		
S5810	199	0		29	10	S5810_199_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																						2		
S5810	199	0		29	10	S5810_199_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	199	0		29	10	S5810_199_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	200	0		29	10	S5810_200_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	200	0		29	10	S5810_200_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	200	0		29	10	S5810_200_0	4	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																						2		
S5810	200	0		29	10	S5810_200_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																						2		
S5810	200	0		29	10	S5810_200_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	91.00	273.00									91.00					258.00			273.00		91.00			
S5810	200	0		29	10	S5810_200_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	200	0		29	10	S5810_200_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	200	0		29	10	S5810_200_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	200	0		29	10	S5810_200_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	200	0		29	10	S5810_200_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	201	0		29	10	S5810_201_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	85.00	255.00									85.00					240.00			255.00		85.00			
S5810	201	0		29	10	S5810_201_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	201	0		29	10	S5810_201_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	201	0		29	10	S5810_201_0	4	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																						2		
S5810	201	0		29	10	S5810_201_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	34.00	102.00									34.00					87.00			102.00		34.00			
S5810	201	0		29	10	S5810_201_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	201	0		29	10	S5810_201_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	201	0		29	10	S5810_201_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	201	0		29	10	S5810_201_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	31.00	93.00									31.00					78.00			93.00		31.00			
S5810	201	0		29	10	S5810_201_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																						2		
S5810	202	0		29	10	S5810_202_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	202	0		29	10	S5810_202_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	202	0		29	10	S5810_202_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	35.00	105.00									35.00					90.00			105.00		35.00			
S5810	202	0		29	10	S5810_202_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	84.00	252.00									84.00					237.00			252.00		84.00			
S5810	202	0		29	10	S5810_202_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	202	0		29	10	S5810_202_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	202	0		29	10	S5810_202_0	4	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																						2		
S5810	202	0		29	10	S5810_202_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																						2		
S5810	202	0		29	10	S5810_202_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	202	0		29	10	S5810_202_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	203	0		29	10	S5810_203_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	85.00	255.00									85.00					240.00			255.00		85.00			
S5810	203	0		29	10	S5810_203_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	203	0		29	10	S5810_203_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	203	0		29	10	S5810_203_0	4	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																						2		
S5810	203	0		29	10	S5810_203_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	203	0		29	10	S5810_203_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	203	0		29	10	S5810_203_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	203	0		29	10	S5810_203_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	203	0		29	10	S5810_203_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	203	0		29	10	S5810_203_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																						2		
S5810	204	0		29	10	S5810_204_0	4	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	7.00	21.00									7.00					21.00			21.00		7.00			
S5810	204	0		29	10	S5810_204_0	4	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	37.00	111.00									37.00					96.00			111.00		37.00			
S5810	204	0		29	10	S5810_204_0	4	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	204	0		29	10	S5810_204_0	4	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	91.00	273.00									91.00					258.00			273.00		91.00			
S5810	204	0		29	10	S5810_204_0	4	5	4	3	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty																								Tier 5 - Specialty		Tier 5 - Specialty																						Tier 5 - Specialty																						2		
S5810	204	0		29	10	S5810_204_0	4	1	4	3	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	16.00	48.00									16.00					48.00			48.00		16.00	1	1	
S5810	204	0		29	10	S5810_204_0	4	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																						2		
S5810	204	0		29	10	S5810_204_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																						2		
S5810	204	0		29	10	S5810_204_0	4	4	4	3	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand																								Tier 4 - Non-Preferred Brand		Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand																						2		
S5810	204	0		29	10	S5810_204_0	4	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	205	0		29	10	S5810_205_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	205	0		29	10	S5810_205_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	205	0		29	10	S5810_205_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	205	0		29	10	S5810_205_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	205	0		29	10	S5810_205_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	206	0		29	10	S5810_206_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	206	0		29	10	S5810_206_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	34.00	102.00									34.00					87.00			102.00		34.00			
S5810	206	0		29	10	S5810_206_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	206	0		29	10	S5810_206_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	206	0		29	10	S5810_206_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	207	0		29	10	S5810_207_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	207	0		29	10	S5810_207_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				29.00	72.50		34.00	102.00			34.00					87.00			102.00		34.00			
S5810	207	0		29	10	S5810_207_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	207	0		29	10	S5810_207_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	207	0		29	10	S5810_207_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				32.00	80.00		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	208	0		29	10	S5810_208_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					15.00			15.00		5.00			
S5810	208	0		29	10	S5810_208_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					81.00			96.00		32.00			
S5810	208	0		29	10	S5810_208_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				36.00	90.00		36.00	108.00			36.00					93.00			108.00		36.00			
S5810	208	0		29	10	S5810_208_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	208	0		29	10	S5810_208_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	209	0		29	10	S5810_209_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					15.00			15.00		5.00			
S5810	209	0		29	10	S5810_209_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					81.00			96.00		32.00			
S5810	209	0		29	10	S5810_209_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	209	0		29	10	S5810_209_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	209	0		29	10	S5810_209_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	210	0		29	10	S5810_210_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	210	0		29	10	S5810_210_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				35.00	87.50		35.00	105.00			35.00					90.00			105.00		35.00			
S5810	210	0		29	10	S5810_210_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					81.00			96.00		32.00			
S5810	210	0		29	10	S5810_210_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					15.00			15.00		5.00			
S5810	210	0		29	10	S5810_210_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	211	0		29	10	S5810_211_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	211	0		29	10	S5810_211_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	211	0		29	10	S5810_211_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	211	0		29	10	S5810_211_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	211	0		29	10	S5810_211_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	212	0		29	10	S5810_212_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	212	0		29	10	S5810_212_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	212	0		29	10	S5810_212_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	212	0		29	10	S5810_212_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	212	0		29	10	S5810_212_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	213	0		29	10	S5810_213_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	213	0		29	10	S5810_213_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	213	0		29	10	S5810_213_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	213	0		29	10	S5810_213_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	213	0		29	10	S5810_213_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	214	0		29	10	S5810_214_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	214	0		29	10	S5810_214_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	214	0		29	10	S5810_214_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	214	0		29	10	S5810_214_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	214	0		29	10	S5810_214_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	215	0		29	10	S5810_215_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				33.00	82.50		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	215	0		29	10	S5810_215_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	215	0		29	10	S5810_215_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	215	0		29	10	S5810_215_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	215	0		29	10	S5810_215_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	216	0		29	10	S5810_216_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	216	0		29	10	S5810_216_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	216	0		29	10	S5810_216_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	216	0		29	10	S5810_216_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	216	0		29	10	S5810_216_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	217	0		29	10	S5810_217_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	217	0		29	10	S5810_217_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	217	0		29	10	S5810_217_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	217	0		29	10	S5810_217_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	217	0		29	10	S5810_217_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	218	0		29	10	S5810_218_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	218	0		29	10	S5810_218_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	218	0		29	10	S5810_218_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	218	0		29	10	S5810_218_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	218	0		29	10	S5810_218_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	219	0		29	10	S5810_219_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	219	0		29	10	S5810_219_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	219	0		29	10	S5810_219_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	219	0		29	10	S5810_219_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	219	0		29	10	S5810_219_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	220	0		29	10	S5810_220_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	220	0		29	10	S5810_220_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	220	0		29	10	S5810_220_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	220	0		29	10	S5810_220_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	220	0		29	10	S5810_220_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	221	0		29	10	S5810_221_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	221	0		29	10	S5810_221_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	221	0		29	10	S5810_221_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	221	0		29	10	S5810_221_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	221	0		29	10	S5810_221_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	222	0		29	10	S5810_222_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	222	0		29	10	S5810_222_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	222	0		29	10	S5810_222_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	222	0		29	10	S5810_222_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	222	0		29	10	S5810_222_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	223	0		29	10	S5810_223_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	223	0		29	10	S5810_223_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	223	0		29	10	S5810_223_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	223	0		29	10	S5810_223_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	223	0		29	10	S5810_223_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	224	0		29	10	S5810_224_0	3	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	224	0		29	10	S5810_224_0	3	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	224	0		29	10	S5810_224_0	3	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	224	0		29	10	S5810_224_0	3	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	224	0		29	10	S5810_224_0	3	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	225	0		29	10	S5810_225_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	225	0		29	10	S5810_225_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	225	0		29	10	S5810_225_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	225	0		29	10	S5810_225_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	36.00	108.00									36.00					93.00			108.00		36.00			
S5810	225	0		29	10	S5810_225_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	226	0		29	10	S5810_226_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	226	0		29	10	S5810_226_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				38.00	95.00		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	226	0		29	10	S5810_226_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				5.00	12.50		5.00	15.00			5.00					15.00			15.00		5.00			
S5810	226	0		29	10	S5810_226_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				32.00	80.00		32.00	96.00			32.00					81.00			96.00		32.00			
S5810	226	0		29	10	S5810_226_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	227	0		29	10	S5810_227_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	227	0		29	10	S5810_227_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	227	0		29	10	S5810_227_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	227	0		29	10	S5810_227_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	227	0		29	10	S5810_227_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	228	0		29	10	S5810_228_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	228	0		29	10	S5810_228_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	228	0		29	10	S5810_228_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	228	0		29	10	S5810_228_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	228	0		29	10	S5810_228_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	229	0		29	10	S5810_229_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand	38.00	114.00									38.00					99.00			114.00		38.00			
S5810	229	0		29	10	S5810_229_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic	32.00	96.00									32.00					81.00			96.00		32.00			
S5810	229	0		29	10	S5810_229_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	111000000001000010010	31	90									10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty	33	33									33					33			33		33	Tier 5 - Specialty																								
S5810	229	0		29	10	S5810_229_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	111000000001000010010	31	90									10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic	5.00	15.00									5.00					15.00			15.00		5.00			
S5810	229	0		29	10	S5810_229_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	111000000001000010010	31	90									10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand	80.00	240.00									80.00					225.00			240.00		80.00			
S5810	230	0		29	10	S5810_230_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	230	0		29	10	S5810_230_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	230	0		29	10	S5810_230_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	230	0		29	10	S5810_230_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	230	0		29	10	S5810_230_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	231	0		29	10	S5810_231_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	231	0		29	10	S5810_231_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				33.00	82.50		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	231	0		29	10	S5810_231_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	231	0		29	10	S5810_231_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	231	0		29	10	S5810_231_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	232	0		29	10	S5810_232_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	232	0		29	10	S5810_232_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	232	0		29	10	S5810_232_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	232	0		29	10	S5810_232_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	232	0		29	10	S5810_232_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	233	0		29	10	S5810_233_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	233	0		29	10	S5810_233_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	233	0		29	10	S5810_233_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	233	0		29	10	S5810_233_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		39.00	117.00			39.00					102.00			117.00		39.00			
S5810	233	0		29	10	S5810_233_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	234	0		29	10	S5810_234_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	234	0		29	10	S5810_234_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	234	0		29	10	S5810_234_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				33.00	82.50		38.00	114.00			38.00					99.00			114.00		38.00			
S5810	234	0		29	10	S5810_234_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	234	0		29	10	S5810_234_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	235	0		29	10	S5810_235_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	235	0		29	10	S5810_235_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	235	0		29	10	S5810_235_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				32.00	80.00		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	235	0		29	10	S5810_235_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				27.00	67.50		32.00	96.00			32.00					81.00			96.00		32.00			
S5810	235	0		29	10	S5810_235_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	236	0		29	10	S5810_236_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	236	0		29	10	S5810_236_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	236	0		29	10	S5810_236_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				32.00	80.00		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	236	0		29	10	S5810_236_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	236	0		29	10	S5810_236_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				27.00	67.50		32.00	96.00			32.00					81.00			96.00		32.00			
S5810	237	0		29	10	S5810_237_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	237	0		29	10	S5810_237_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	237	0		29	10	S5810_237_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	237	0		29	10	S5810_237_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	237	0		29	10	S5810_237_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5810	238	0		29	10	S5810_238_0	2	2	4	1	Tier 2 - Non-Preferred Generic	000100	3	2	2	Tier 2 - Non-Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 2 - Non-Preferred Generic	2	Tier 2 - Non-Preferred Generic																						Tier 2 - Non-Preferred Generic				28.00	70.00		33.00	99.00			33.00					84.00			99.00		33.00			
S5810	238	0		29	10	S5810_238_0	2	1	4	1	Tier 1 - Preferred Generic	001000	3	2	2	Tier 1 - Preferred Generic	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 1 - Preferred Generic	2	Tier 1 - Preferred Generic																						Tier 1 - Preferred Generic				2.00	5.00		5.00	15.00			5.00					0.00			15.00		5.00			
S5810	238	0		29	10	S5810_238_0	2	3	4	1	Tier 3 - Preferred Brand	000001	1	2	2	Tier 3 - Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 3 - Preferred Brand	2	Tier 3 - Preferred Brand																						Tier 3 - Preferred Brand				34.00	85.00		37.00	111.00			37.00					96.00			111.00		37.00			
S5810	238	0		29	10	S5810_238_0	2	4	4	1	Tier 4 - Non-Preferred Brand	100000	1	2	1	Tier 4 - Non-Preferred Brand	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 4 - Non-Preferred Brand	2	Tier 4 - Non-Preferred Brand																						Tier 4 - Non-Preferred Brand				80.00	200.00		80.00	240.00			80.00					225.00			240.00		80.00			
S5810	238	0		29	10	S5810_238_0	2	5	4	1	Tier 5 - Specialty	010010	1	1	2	Tier 5 - Specialty	100011011001000010010				31	90		31	90			10					90			90		31	1	Tier 5 - Specialty	1	Tier 5 - Specialty				33	33		33	33			33					33			33		33	Tier 5 - Specialty																								
S5820	001	0		29	10	S5820_001_0	5	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						10.00			21.00		7.00			
S5820	001	0		29	10	S5820_001_0	5	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	43.00	129.00								43.00						114.00			129.00		43.00			
S5820	001	0		29	10	S5820_001_0	5	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	001	0		29	10	S5820_001_0	5	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	002	0		29	10	S5820_002_0	4	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	94.00	282.00								94.00						267.00			282.00		94.00			
S5820	002	0		29	10	S5820_002_0	4	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	002	0		29	10	S5820_002_0	4	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	43.00	129.00								43.00						114.00			129.00		43.00			
S5820	002	0		29	10	S5820_002_0	4	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	003	0		29	10	S5820_003_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	003	0		29	10	S5820_003_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	003	0		29	10	S5820_003_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	003	0		29	10	S5820_003_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	77.00	231.00								77.00						216.00			231.00		77.00			
S5820	004	0		29	10	S5820_004_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						240.00			255.00		85.00			
S5820	004	0		29	10	S5820_004_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	004	0		29	10	S5820_004_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	004	0		29	10	S5820_004_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	005	0		29	10	S5820_005_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	005	0		29	10	S5820_005_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	005	0		29	10	S5820_005_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	005	0		29	10	S5820_005_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	006	0		29	10	S5820_006_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	006	0		29	10	S5820_006_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	006	0		29	10	S5820_006_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	74.50	223.50								74.50						208.50			223.50		74.50			
S5820	006	0		29	10	S5820_006_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	007	0		29	10	S5820_007_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	007	0		29	10	S5820_007_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	69.25	207.75								69.25						192.75			207.75		69.25			
S5820	007	0		29	10	S5820_007_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	007	0		29	10	S5820_007_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	008	0		29	10	S5820_008_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	008	0		29	10	S5820_008_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	008	0		29	10	S5820_008_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.75	218.25								72.75						203.25			218.25		72.75			
S5820	008	0		29	10	S5820_008_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	009	0		29	10	S5820_009_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	63.75	191.25								63.75						176.25			191.25		63.75			
S5820	009	0		29	10	S5820_009_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	009	0		29	10	S5820_009_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	009	0		29	10	S5820_009_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	010	0		29	10	S5820_010_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	010	0		29	10	S5820_010_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	010	0		29	10	S5820_010_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	68.50	205.50								68.50						190.50			205.50		68.50			
S5820	010	0		29	10	S5820_010_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	011	0		29	10	S5820_011_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	011	0		29	10	S5820_011_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	63.25	189.75								63.25						174.75			189.75		63.25			
S5820	011	0		29	10	S5820_011_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	011	0		29	10	S5820_011_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	012	0		29	10	S5820_012_0	4	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	012	0		29	10	S5820_012_0	4	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	95.00	285.00								95.00						270.00			285.00		95.00			
S5820	012	0		29	10	S5820_012_0	4	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	44.00	132.00								44.00						117.00			132.00		44.00			
S5820	012	0		29	10	S5820_012_0	4	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	013	0		29	10	S5820_013_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	013	0		29	10	S5820_013_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	013	0		29	10	S5820_013_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.50	238.50								79.50						223.50			238.50		79.50			
S5820	013	0		29	10	S5820_013_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	014	0		29	10	S5820_014_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	014	0		29	10	S5820_014_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	71.00	213.00								71.00						198.00			213.00		71.00			
S5820	014	0		29	10	S5820_014_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	014	0		29	10	S5820_014_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	015	0		29	10	S5820_015_0	4	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	015	0		29	10	S5820_015_0	4	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	015	0		29	10	S5820_015_0	4	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	44.00	132.00								44.00						117.00			132.00		44.00			
S5820	015	0		29	10	S5820_015_0	4	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	016	0		29	10	S5820_016_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	73.75	221.25								73.75						206.25			221.25		73.75			
S5820	016	0		29	10	S5820_016_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	016	0		29	10	S5820_016_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	016	0		29	10	S5820_016_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	017	0		29	10	S5820_017_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	017	0		29	10	S5820_017_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	017	0		29	10	S5820_017_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	017	0		29	10	S5820_017_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	76.00	228.00								76.00						213.00			228.00		76.00			
S5820	018	0		29	10	S5820_018_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	018	0		29	10	S5820_018_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	67.00	201.00								67.00						186.00			201.00		67.00			
S5820	018	0		29	10	S5820_018_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	018	0		29	10	S5820_018_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	019	0		29	10	S5820_019_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	019	0		29	10	S5820_019_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	62.75	188.25								62.75						173.25			188.25		62.75			
S5820	019	0		29	10	S5820_019_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	019	0		29	10	S5820_019_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	020	0		29	10	S5820_020_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	020	0		29	10	S5820_020_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	54.50	163.50								54.50						148.50			163.50		54.50			
S5820	020	0		29	10	S5820_020_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	020	0		29	10	S5820_020_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	021	0		29	10	S5820_021_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	64.00	192.00								64.00						177.00			192.00		64.00			
S5820	021	0		29	10	S5820_021_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	021	0		29	10	S5820_021_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	021	0		29	10	S5820_021_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	022	0		29	10	S5820_022_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	022	0		29	10	S5820_022_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	022	0		29	10	S5820_022_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	66.25	198.75								66.25						183.75			198.75		66.25			
S5820	022	0		29	10	S5820_022_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	023	0		29	10	S5820_023_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	67.00	201.00								67.00						186.00			201.00		67.00			
S5820	023	0		29	10	S5820_023_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	023	0		29	10	S5820_023_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	023	0		29	10	S5820_023_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	024	0		29	10	S5820_024_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	69.00	207.00								69.00						192.00			207.00		69.00			
S5820	024	0		29	10	S5820_024_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	024	0		29	10	S5820_024_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	024	0		29	10	S5820_024_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	025	0		29	10	S5820_025_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	025	0		29	10	S5820_025_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	025	0		29	10	S5820_025_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	77.00	231.00								77.00						216.00			231.00		77.00			
S5820	025	0		29	10	S5820_025_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	026	0		29	10	S5820_026_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	81.00	243.00								81.00						228.00			243.00		81.00			
S5820	026	0		29	10	S5820_026_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	026	0		29	10	S5820_026_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	026	0		29	10	S5820_026_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	027	0		29	10	S5820_027_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	027	0		29	10	S5820_027_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						222.00			237.00		79.00			
S5820	027	0		29	10	S5820_027_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	027	0		29	10	S5820_027_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	028	0		29	10	S5820_028_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	028	0		29	10	S5820_028_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	028	0		29	10	S5820_028_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	82.00	246.00								82.00						231.00			246.00		82.00			
S5820	028	0		29	10	S5820_028_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	029	0		29	10	S5820_029_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	029	0		29	10	S5820_029_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	029	0		29	10	S5820_029_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	73.00	219.00								73.00						204.00			219.00		73.00			
S5820	029	0		29	10	S5820_029_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	030	0		29	10	S5820_030_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	030	0		29	10	S5820_030_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	030	0		29	10	S5820_030_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	030	0		29	10	S5820_030_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.00	225.00								75.00						210.00			225.00		75.00			
S5820	031	0		29	10	S5820_031_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	76.00	228.00								76.00						213.00			228.00		76.00			
S5820	031	0		29	10	S5820_031_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	031	0		29	10	S5820_031_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	031	0		29	10	S5820_031_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	032	0		29	10	S5820_032_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	95.00	285.00								95.00						270.00			285.00		95.00			
S5820	032	0		29	10	S5820_032_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						120.00			135.00		45.00			
S5820	032	0		29	10	S5820_032_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	032	0		29	10	S5820_032_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						10.00			21.00		7.00			
S5820	033	0		29	10	S5820_033_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	95.00	285.00								95.00						270.00			285.00		95.00			
S5820	033	0		29	10	S5820_033_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	033	0		29	10	S5820_033_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	43.00	129.00								43.00						114.00			129.00		43.00			
S5820	033	0		29	10	S5820_033_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	034	0		29	10	S5820_034_0	4	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	30.00	90.00								30.00						75.00			90.00		30.00			
S5820	034	0		29	10	S5820_034_0	4	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	71.50	214.50								71.50						199.50			214.50		71.50			
S5820	034	0		29	10	S5820_034_0	4	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	034	0		29	10	S5820_034_0	4	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	10.00	30.00								10.00						10.00			30.00		10.00			
S5820	035	0		29	10	S5820_035_0	4	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	035	0		29	10	S5820_035_0	4	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	40.00	120.00								40.00						105.00			120.00		40.00			
S5820	035	0		29	10	S5820_035_0	4	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	10.00	30.00								10.00						14.00			30.00		10.00			
S5820	035	0		29	10	S5820_035_0	4	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	036	0		29	10	S5820_036_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	036	0		29	10	S5820_036_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	036	0		29	10	S5820_036_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	036	0		29	10	S5820_036_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	55.00	165.00								55.00						155.00			165.00		55.00			
S5820	037	0		29	10	S5820_037_0	2	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	037	0		29	10	S5820_037_0	2	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	037	0		29	10	S5820_037_0	2	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	037	0		29	10	S5820_037_0	2	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	52.00	156.00								52.00						141.00			156.00		52.00			
S5820	038	0		29	10	S5820_038_0	3	1	3	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	8.00	24.00								8.00						10.00			24.00		8.00			
S5820	038	0		29	10	S5820_038_0	3	2	3	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	41.00	123.00								41.00						108.00			123.00		41.00			
S5820	038	0		29	10	S5820_038_0	3	3	3	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						240.00			255.00		85.00			
S5820	038	0		29	10	S5820_038_0	3	4	3	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	142	0		29	10	S5820_142_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	142	0		29	10	S5820_142_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	142	0		29	10	S5820_142_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	142	0		29	10	S5820_142_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	142	0		29	10	S5820_142_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5820	142	0		29	10	S5820_142_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5820	142	0		29	10	S5820_142_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5820	142	0		29	10	S5820_142_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5820	143	0		29	10	S5820_143_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5820	143	0		29	10	S5820_143_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5820	143	0		29	10	S5820_143_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	143	0		29	10	S5820_143_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	143	0		29	10	S5820_143_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	143	0		29	10	S5820_143_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	143	0		29	10	S5820_143_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5820	143	0		29	10	S5820_143_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5820	144	0		29	10	S5820_144_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	144	0		29	10	S5820_144_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	144	0		29	10	S5820_144_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	144	0		29	10	S5820_144_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5820	144	0		29	10	S5820_144_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5820	144	0		29	10	S5820_144_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5820	144	0		29	10	S5820_144_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5820	144	0		29	10	S5820_144_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	145	0		29	10	S5820_145_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	145	0		29	10	S5820_145_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5820	145	0		29	10	S5820_145_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5820	145	0		29	10	S5820_145_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5820	145	0		29	10	S5820_145_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5820	145	0		29	10	S5820_145_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	145	0		29	10	S5820_145_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	145	0		29	10	S5820_145_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	146	0		29	10	S5820_146_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5820	146	0		29	10	S5820_146_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5820	146	0		29	10	S5820_146_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5820	146	0		29	10	S5820_146_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5820	146	0		29	10	S5820_146_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5820	146	0		29	10	S5820_146_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5820	146	0		29	10	S5820_146_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5820	146	0		29	10	S5820_146_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5820	147	0		29	10	S5820_147_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5820	147	0		29	10	S5820_147_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5820	147	0		29	10	S5820_147_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	86.00	258.00								86.00						243.00			258.00		86.00			
S5820	147	0		29	10	S5820_147_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5820	148	0		29	10	S5820_148_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5820	148	0		29	10	S5820_148_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5820	148	0		29	10	S5820_148_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.50	256.50								85.50						241.50			256.50		85.50			
S5820	148	0		29	10	S5820_148_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5820	149	0		29	10	S5820_149_0	3	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5820	149	0		29	10	S5820_149_0	3	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5820	149	0		29	10	S5820_149_0	3	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	26.00	78.00								26.00						63.00			78.00		26.00			
S5820	149	0		29	10	S5820_149_0	3	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	95.00	285.00								95.00						270.00			285.00		95.00			
S5820	150	0		29	10	S5820_150_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	81.50	244.50								81.50						229.50			244.50		81.50			
S5820	150	0		29	10	S5820_150_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5820	150	0		29	10	S5820_150_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5820	150	0		29	10	S5820_150_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5820	151	0		29	10	S5820_151_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5820	151	0		29	10	S5820_151_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	79.00	237.00								79.00						222.00			237.00		79.00			
S5820	151	0		29	10	S5820_151_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5820	151	0		29	10	S5820_151_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5825	017	0		29	10	S5825_017_0	2	2	4	1	Brand	000010	1	2	1	Brand	111000000010010000000	30	90								30			90								34	2	Brand	2	Brand																						Brand	43.00	86.00								43.00			86.00								43.00			
S5825	017	0		29	10	S5825_017_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								34	2	Generic	2	Generic																						Generic	6.00	12.00								6.00			12.00								6.00			
S5825	017	0		29	10	S5825_017_0	2	3	4	1	Specialty	010010	1	1	2	Specialty	110000000010000000000	30									30											34		Specialty	1	Specialty	29									29											29	Specialty																								
S5825	085	0		29	10	S5825_085_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000000000	30	90								30											34	2	Specialty	1	Specialty	33	33								33											33	Specialty																								
S5825	085	0		29	10	S5825_085_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00	1	1	
S5825	085	0		29	10	S5825_085_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5825	085	0		29	10	S5825_085_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5825	085	0		29	10	S5825_085_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000000000	30	90								30											34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	65.00	195.00								65.00											65.00			
S5825	085	0		29	10	S5825_085_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000000000	30	90								30											34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00								35.00											35.00			
S5825	085	0		29	10	S5825_085_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000000000	30	90								30											34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00											6.00			
S5825	085	0		29	10	S5825_085_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5840	002	0		29	10	S5840_002_0	3	1	4	1	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	5.00	15.00								5.00											5.00			
S5840	002	0		29	10	S5840_002_0	3	2	4	1	2	000001	1	2	2	2	111000000010000000000	30	90								30											31	2	2	2	2																						2	15.00	45.00								15.00											15.00			
S5840	002	0		29	10	S5840_002_0	3	3	4	1	3	100000	1	2	1	3	111000000010000000000	30	90								30											31	1	3	2	3																						3	30.00	90.00								30.00											30.00			
S5840	002	0		29	10	S5840_002_0	3	4	4	1	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																								
S5840	002	0		29	10	S5840_002_0	3	1	4	3	1	010000	1	2	2	1	111000000010000000000	30	90								30											31	2	1	2	1																						1	5.00	15.00								5.00											5.00	1	1	
S5840	002	0		29	10	S5840_002_0	3	2	4	3	2	000001	1	2	2	2																								2		2																						2																						2		
S5840	002	0		29	10	S5840_002_0	3	3	4	3	3	100000	1	2	1	3																								3		3																						3																						2		
S5840	002	0		29	10	S5840_002_0	3	4	4	3	4	110001	1	1	2	4	111000000010000000000	30	90								30											31	2	4	1	4	25	25								25											25	4																						1	2	01000000
S5857	001	0		29	10	S5857_001_0	4	1	3	1	Generic	010000		2	2	Generic	111000000010010000000	31	90								31			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			20.00								8.00			
S5857	001	0		29	10	S5857_001_0	4	4	3	1	Specialty Tier	010010		1	2	Specialty Tier	110000000010100000000	31									31		31									31		Specialty Tier	1	Specialty Tier	33									33		33									33	Specialty Tier																								
S5857	001	0		29	10	S5857_001_0	4	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	79.00	237.00								79.00			197.50								79.00			
S5857	001	0		29	10	S5857_001_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	31	90								31			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	43.00	129.00								43.00			107.50								43.00			
S5860	003	0		29	10	S5860_003_0	5	1	3	1	Generic Drugs	010000		2	2	Generic Drugs	111000000010010000000	30	90								30			90								31	1	Generic Drugs	2	Generic Drugs																						Generic Drugs	9.75	29.25								9.75			19.50								9.75			
S5860	003	0		29	10	S5860_003_0	5	4	3	1	Specialty Drugs	010010		1	2	Specialty Drugs	111000000010010000000	30	90								30			90								31	1	Specialty Drugs	1	Specialty Drugs	29	29								29			29								29	Specialty Drugs																								
S5860	003	0		29	10	S5860_003_0	5	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	59.50	178.50								59.50			119.00								59.50			
S5860	003	0		29	10	S5860_003_0	5	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.50	118.50								39.50			79.00								39.50			
S5877	004	0		29	10	S5877_004_0	2	1	2	1	Generic	010000		2	2	Generic	111000000001010000000	34	90									29		90								34	2	Generic	2	Generic																						Generic	3.00	9.00									3.00		9.00								3.00			
S5877	004	0		29	10	S5877_004_0	2	3	2	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000001010000000	34	90									29		90								34	2	Non-Preferred Brand	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	2	4	2	1	Specialty	010010		1	1	Specialty	111000000001010000000	34	90									29		90								34	2	Specialty	2	Specialty																						Specialty	70.00	210.00									70.00		210.00								70.00			
S5877	004	0		29	10	S5877_004_0	2	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000001010000000	34	90									29		90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	35.00	105.00									35.00		105.00								35.00			
S5877	007	0		29	10	S5877_007_0	2	4	4	1	Specialty	010010	1	1	1	Specialty	111000000010010000000	34	90								34			90								34	2	Specialty	1	Specialty	30	30								30			30								30	Specialty																								
S5877	007	0		29	10	S5877_007_0	2	3	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010010000000	34	90								34			90								34	2	Non-Preferred Brand	1	Non-Preferred Brand	50	50								50			50								50	Non-Preferred Brand																								
S5877	007	0		29	10	S5877_007_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	34	90								34			90								34	2	Generic	1	Generic	20	20								20			20								20	Generic																								
S5877	007	0		29	10	S5877_007_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	34	90								34			90								34	2	Preferred Brand	1	Preferred Brand	25	25								25			25								25	Preferred Brand																								
S5884	001	0		29	10	S5884_001_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5884	001	0		29	10	S5884_001_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	001	0		29	10	S5884_001_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	001	0		29	10	S5884_001_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				40.00	120.00		45.00	135.00		40.00					40.00	100.00		40.00	120.00		40.00			
S5884	002	0		29	10	S5884_002_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	002	0		29	10	S5884_002_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				80.00	240.00		85.00	255.00		80.00					80.00	200.00		80.00	240.00		80.00			
S5884	002	0		29	10	S5884_002_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	002	0		29	10	S5884_002_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5884	003	0		29	10	S5884_003_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	003	0		29	10	S5884_003_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	003	0		29	10	S5884_003_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	003	0		29	10	S5884_003_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	004	0		29	10	S5884_004_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	004	0		29	10	S5884_004_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	004	0		29	10	S5884_004_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	004	0		29	10	S5884_004_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5884	005	0		29	10	S5884_005_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5884	005	0		29	10	S5884_005_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	005	0		29	10	S5884_005_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	005	0		29	10	S5884_005_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	006	0		29	10	S5884_006_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	006	0		29	10	S5884_006_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	006	0		29	10	S5884_006_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	006	0		29	10	S5884_006_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	007	0		29	10	S5884_007_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	007	0		29	10	S5884_007_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	007	0		29	10	S5884_007_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	007	0		29	10	S5884_007_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	008	0		29	10	S5884_008_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	008	0		29	10	S5884_008_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	008	0		29	10	S5884_008_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	008	0		29	10	S5884_008_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	009	0		29	10	S5884_009_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				43.00	129.00		48.00	144.00		43.00					43.00	107.50		43.00	129.00		43.00			
S5884	009	0		29	10	S5884_009_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	009	0		29	10	S5884_009_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	009	0		29	10	S5884_009_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	010	0		29	10	S5884_010_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	010	0		29	10	S5884_010_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				40.00	120.00		45.00	135.00		40.00					40.00	100.00		40.00	120.00		40.00			
S5884	010	0		29	10	S5884_010_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				76.00	228.00		81.00	243.00		76.00					76.00	190.00		76.00	228.00		76.00			
S5884	010	0		29	10	S5884_010_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	011	0		29	10	S5884_011_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	011	0		29	10	S5884_011_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	011	0		29	10	S5884_011_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	011	0		29	10	S5884_011_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	012	0		29	10	S5884_012_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	012	0		29	10	S5884_012_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	012	0		29	10	S5884_012_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	012	0		29	10	S5884_012_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	013	0		29	10	S5884_013_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	013	0		29	10	S5884_013_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	013	0		29	10	S5884_013_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	013	0		29	10	S5884_013_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	014	0		29	10	S5884_014_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	014	0		29	10	S5884_014_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	014	0		29	10	S5884_014_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	014	0		29	10	S5884_014_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	015	0		29	10	S5884_015_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	015	0		29	10	S5884_015_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				43.00	129.00		48.00	144.00		43.00					43.00	107.50		43.00	129.00		43.00			
S5884	015	0		29	10	S5884_015_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	015	0		29	10	S5884_015_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	016	0		29	10	S5884_016_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	016	0		29	10	S5884_016_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	016	0		29	10	S5884_016_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	016	0		29	10	S5884_016_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	017	0		29	10	S5884_017_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	017	0		29	10	S5884_017_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	017	0		29	10	S5884_017_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	017	0		29	10	S5884_017_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	018	0		29	10	S5884_018_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	018	0		29	10	S5884_018_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	018	0		29	10	S5884_018_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	018	0		29	10	S5884_018_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	019	0		29	10	S5884_019_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	019	0		29	10	S5884_019_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	019	0		29	10	S5884_019_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				41.00	123.00		46.00	138.00		41.00					41.00	102.50		41.00	123.00		41.00			
S5884	019	0		29	10	S5884_019_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	020	0		29	10	S5884_020_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5884	020	0		29	10	S5884_020_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				42.00	126.00		47.00	141.00		42.00					42.00	105.00		42.00	126.00		42.00			
S5884	020	0		29	10	S5884_020_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				80.00	240.00		85.00	255.00		80.00					80.00	200.00		80.00	240.00		80.00			
S5884	020	0		29	10	S5884_020_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	021	0		29	10	S5884_021_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	021	0		29	10	S5884_021_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	021	0		29	10	S5884_021_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	021	0		29	10	S5884_021_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	022	0		29	10	S5884_022_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	022	0		29	10	S5884_022_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				77.00	231.00		82.00	246.00		77.00					77.00	192.50		77.00	231.00		77.00			
S5884	022	0		29	10	S5884_022_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				44.00	132.00		49.00	147.00		44.00					44.00	110.00		44.00	132.00		44.00			
S5884	022	0		29	10	S5884_022_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	023	0		29	10	S5884_023_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	023	0		29	10	S5884_023_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	023	0		29	10	S5884_023_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	023	0		29	10	S5884_023_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	024	0		29	10	S5884_024_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	024	0		29	10	S5884_024_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				8.00	24.00		13.00	39.00		8.00					0.00	0.00		8.00	24.00		8.00			
S5884	024	0		29	10	S5884_024_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				80.00	240.00		85.00	255.00		80.00					80.00	200.00		80.00	240.00		80.00			
S5884	024	0		29	10	S5884_024_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	025	0		29	10	S5884_025_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	025	0		29	10	S5884_025_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	025	0		29	10	S5884_025_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	025	0		29	10	S5884_025_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	026	0		29	10	S5884_026_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	026	0		29	10	S5884_026_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	026	0		29	10	S5884_026_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	026	0		29	10	S5884_026_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	027	0		29	10	S5884_027_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	027	0		29	10	S5884_027_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	027	0		29	10	S5884_027_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	027	0		29	10	S5884_027_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	028	0		29	10	S5884_028_0	2	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	028	0		29	10	S5884_028_0	2	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	028	0		29	10	S5884_028_0	2	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				85.00	255.00		90.00	270.00		85.00					85.00	212.50		85.00	255.00		85.00			
S5884	028	0		29	10	S5884_028_0	2	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	029	0		29	10	S5884_029_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	029	0		29	10	S5884_029_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	029	0		29	10	S5884_029_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	029	0		29	10	S5884_029_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	030	0		29	10	S5884_030_0	1	1	3	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	030	0		29	10	S5884_030_0	1	4	3	1	Specialty	110110		1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	030	0		29	10	S5884_030_0	1	3	3	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	030	0		29	10	S5884_030_0	1	2	3	1	Non-Preferred Generic/Preferred Brand	000111		2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				44.00	132.00		49.00	147.00		44.00					44.00	110.00		44.00	132.00		44.00			
S5884	031	0		29	10	S5884_031_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	031	0		29	10	S5884_031_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	031	0		29	10	S5884_031_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	031	0		29	10	S5884_031_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	031	0		29	10	S5884_031_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	031	0		29	10	S5884_031_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	031	0		29	10	S5884_031_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	031	0		29	10	S5884_031_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	032	0		29	10	S5884_032_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	032	0		29	10	S5884_032_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	032	0		29	10	S5884_032_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	032	0		29	10	S5884_032_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	032	0		29	10	S5884_032_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	032	0		29	10	S5884_032_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	032	0		29	10	S5884_032_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	032	0		29	10	S5884_032_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	033	0		29	10	S5884_033_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	033	0		29	10	S5884_033_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	033	0		29	10	S5884_033_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	033	0		29	10	S5884_033_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	033	0		29	10	S5884_033_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	033	0		29	10	S5884_033_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	033	0		29	10	S5884_033_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	033	0		29	10	S5884_033_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	034	0		29	10	S5884_034_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	034	0		29	10	S5884_034_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	034	0		29	10	S5884_034_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	034	0		29	10	S5884_034_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	034	0		29	10	S5884_034_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	034	0		29	10	S5884_034_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	034	0		29	10	S5884_034_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	034	0		29	10	S5884_034_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	035	0		29	10	S5884_035_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	035	0		29	10	S5884_035_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	035	0		29	10	S5884_035_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	035	0		29	10	S5884_035_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	035	0		29	10	S5884_035_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	035	0		29	10	S5884_035_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	035	0		29	10	S5884_035_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	035	0		29	10	S5884_035_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	036	0		29	10	S5884_036_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	036	0		29	10	S5884_036_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	036	0		29	10	S5884_036_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	036	0		29	10	S5884_036_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	036	0		29	10	S5884_036_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	036	0		29	10	S5884_036_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	036	0		29	10	S5884_036_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	036	0		29	10	S5884_036_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	037	0		29	10	S5884_037_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	037	0		29	10	S5884_037_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	037	0		29	10	S5884_037_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	037	0		29	10	S5884_037_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	037	0		29	10	S5884_037_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	037	0		29	10	S5884_037_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	037	0		29	10	S5884_037_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	037	0		29	10	S5884_037_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	038	0		29	10	S5884_038_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	038	0		29	10	S5884_038_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	038	0		29	10	S5884_038_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	038	0		29	10	S5884_038_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	038	0		29	10	S5884_038_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	038	0		29	10	S5884_038_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	038	0		29	10	S5884_038_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	038	0		29	10	S5884_038_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	039	0		29	10	S5884_039_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	039	0		29	10	S5884_039_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	039	0		29	10	S5884_039_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	039	0		29	10	S5884_039_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	039	0		29	10	S5884_039_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	039	0		29	10	S5884_039_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	039	0		29	10	S5884_039_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	039	0		29	10	S5884_039_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	040	0		29	10	S5884_040_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	040	0		29	10	S5884_040_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	040	0		29	10	S5884_040_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	040	0		29	10	S5884_040_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	040	0		29	10	S5884_040_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	040	0		29	10	S5884_040_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	040	0		29	10	S5884_040_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	040	0		29	10	S5884_040_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	041	0		29	10	S5884_041_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	041	0		29	10	S5884_041_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	041	0		29	10	S5884_041_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	041	0		29	10	S5884_041_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		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	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	041	0		29	10	S5884_041_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	041	0		29	10	S5884_041_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	041	0		29	10	S5884_041_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	042	0		29	10	S5884_042_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	042	0		29	10	S5884_042_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	042	0		29	10	S5884_042_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	042	0		29	10	S5884_042_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	042	0		29	10	S5884_042_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	042	0		29	10	S5884_042_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	042	0		29	10	S5884_042_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	042	0		29	10	S5884_042_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	043	0		29	10	S5884_043_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	043	0		29	10	S5884_043_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	043	0		29	10	S5884_043_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	043	0		29	10	S5884_043_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	043	0		29	10	S5884_043_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	043	0		29	10	S5884_043_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	043	0		29	10	S5884_043_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	043	0		29	10	S5884_043_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	044	0		29	10	S5884_044_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	044	0		29	10	S5884_044_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	044	0		29	10	S5884_044_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	044	0		29	10	S5884_044_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	044	0		29	10	S5884_044_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	044	0		29	10	S5884_044_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	044	0		29	10	S5884_044_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	044	0		29	10	S5884_044_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	045	0		29	10	S5884_045_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	045	0		29	10	S5884_045_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	045	0		29	10	S5884_045_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	045	0		29	10	S5884_045_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	045	0		29	10	S5884_045_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	045	0		29	10	S5884_045_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	045	0		29	10	S5884_045_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	045	0		29	10	S5884_045_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	046	0		29	10	S5884_046_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	046	0		29	10	S5884_046_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	046	0		29	10	S5884_046_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	046	0		29	10	S5884_046_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	046	0		29	10	S5884_046_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	046	0		29	10	S5884_046_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	046	0		29	10	S5884_046_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	046	0		29	10	S5884_046_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	047	0		29	10	S5884_047_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	047	0		29	10	S5884_047_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	047	0		29	10	S5884_047_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	047	0		29	10	S5884_047_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	047	0		29	10	S5884_047_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	047	0		29	10	S5884_047_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	047	0		29	10	S5884_047_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	047	0		29	10	S5884_047_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	048	0		29	10	S5884_048_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	048	0		29	10	S5884_048_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	048	0		29	10	S5884_048_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	048	0		29	10	S5884_048_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	048	0		29	10	S5884_048_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	048	0		29	10	S5884_048_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	048	0		29	10	S5884_048_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	048	0		29	10	S5884_048_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	049	0		29	10	S5884_049_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				40.00	120.00		45.00	135.00		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	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	049	0		29	10	S5884_049_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	049	0		29	10	S5884_049_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	049	0		29	10	S5884_049_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	049	0		29	10	S5884_049_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	049	0		29	10	S5884_049_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	049	0		29	10	S5884_049_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	050	0		29	10	S5884_050_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	050	0		29	10	S5884_050_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	050	0		29	10	S5884_050_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	050	0		29	10	S5884_050_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	050	0		29	10	S5884_050_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	050	0		29	10	S5884_050_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				40.00	120.00		45.00	135.00		40.00					40.00	100.00		40.00	120.00		40.00			
S5884	050	0		29	10	S5884_050_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		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	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	051	0		29	10	S5884_051_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	051	0		29	10	S5884_051_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	051	0		29	10	S5884_051_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	051	0		29	10	S5884_051_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	051	0		29	10	S5884_051_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	051	0		29	10	S5884_051_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	051	0		29	10	S5884_051_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	051	0		29	10	S5884_051_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	052	0		29	10	S5884_052_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	052	0		29	10	S5884_052_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				40.00	120.00		45.00	135.00		40.00					40.00	100.00		40.00	120.00		40.00			
S5884	052	0		29	10	S5884_052_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	052	0		29	10	S5884_052_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	052	0		29	10	S5884_052_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	052	0		29	10	S5884_052_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	052	0		29	10	S5884_052_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	052	0		29	10	S5884_052_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	053	0		29	10	S5884_053_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	053	0		29	10	S5884_053_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	053	0		29	10	S5884_053_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	053	0		29	10	S5884_053_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	053	0		29	10	S5884_053_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	053	0		29	10	S5884_053_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	053	0		29	10	S5884_053_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	053	0		29	10	S5884_053_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	058	0		29	10	S5884_058_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	058	0		29	10	S5884_058_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	058	0		29	10	S5884_058_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	058	0		29	10	S5884_058_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	058	0		29	10	S5884_058_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	058	0		29	10	S5884_058_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	058	0		29	10	S5884_058_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	058	0		29	10	S5884_058_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	059	0		29	10	S5884_059_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	059	0		29	10	S5884_059_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	059	0		29	10	S5884_059_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	059	0		29	10	S5884_059_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	059	0		29	10	S5884_059_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	059	0		29	10	S5884_059_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	059	0		29	10	S5884_059_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	059	0		29	10	S5884_059_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	060	0		29	10	S5884_060_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	060	0		29	10	S5884_060_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	060	0		29	10	S5884_060_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	060	0		29	10	S5884_060_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	060	0		29	10	S5884_060_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	060	0		29	10	S5884_060_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	060	0		29	10	S5884_060_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	060	0		29	10	S5884_060_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	062	0		29	10	S5884_062_0	2	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	062	0		29	10	S5884_062_0	2	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	062	0		29	10	S5884_062_0	2	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				40	40		45	45		40					40	40		40	40		40	Non-Preferred Brand																								
S5884	065	0		29	10	S5884_065_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	065	0		29	10	S5884_065_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	065	0		29	10	S5884_065_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				43	43		48	48		43					43	43		43	43		43	Non-Preferred Brand																								
S5884	066	0		29	10	S5884_066_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				42	42		47	47		42					42	42		42	42		42	Non-Preferred Brand																								
S5884	066	0		29	10	S5884_066_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	066	0		29	10	S5884_066_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	071	0		29	10	S5884_071_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	071	0		29	10	S5884_071_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				44	44		49	49		44					44	44		44	44		44	Non-Preferred Brand																								
S5884	071	0		29	10	S5884_071_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	072	0		29	10	S5884_072_0	2	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	072	0		29	10	S5884_072_0	2	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				44	44		49	49		44					44	44		44	44		44	Non-Preferred Brand																								
S5884	072	0		29	10	S5884_072_0	2	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	073	0		29	10	S5884_073_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				44	44		49	49		44					44	44		44	44		44	Non-Preferred Brand																								
S5884	073	0		29	10	S5884_073_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	073	0		29	10	S5884_073_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	074	0		29	10	S5884_074_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	074	0		29	10	S5884_074_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	074	0		29	10	S5884_074_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				44	44		49	49		44					44	44		44	44		44	Non-Preferred Brand																								
S5884	076	0		29	10	S5884_076_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	076	0		29	10	S5884_076_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				44	44		49	49		44					44	44		44	44		44	Non-Preferred Brand																								
S5884	076	0		29	10	S5884_076_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	077	0		29	10	S5884_077_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				43	43		48	48		43					43	43		43	43		43	Non-Preferred Brand																								
S5884	077	0		29	10	S5884_077_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	077	0		29	10	S5884_077_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	078	0		29	10	S5884_078_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	078	0		29	10	S5884_078_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	078	0		29	10	S5884_078_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				43	43		48	48		43					43	43		43	43		43	Non-Preferred Brand																								
S5884	083	0		29	10	S5884_083_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				43	43		48	48		43					43	43		43	43		43	Non-Preferred Brand																								
S5884	083	0		29	10	S5884_083_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	083	0		29	10	S5884_083_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	085	0		29	10	S5884_085_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				41	41		46	46		41					41	41		41	41		41	Non-Preferred Brand																								
S5884	085	0		29	10	S5884_085_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	085	0		29	10	S5884_085_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	086	0		29	10	S5884_086_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	086	0		29	10	S5884_086_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	086	0		29	10	S5884_086_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				39	39		44	44		39					39	39		39	39		39	Non-Preferred Brand																								
S5884	087	0		29	10	S5884_087_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				43	43		48	48		43					43	43		43	43		43	Non-Preferred Brand																								
S5884	087	0		29	10	S5884_087_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	087	0		29	10	S5884_087_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	089	0		29	10	S5884_089_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				43	43		48	48		43					43	43		43	43		43	Non-Preferred Brand																								
S5884	089	0		29	10	S5884_089_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	089	0		29	10	S5884_089_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	092	0		29	10	S5884_092_0	2	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				42	42		47	47		42					42	42		42	42		42	Non-Preferred Brand																								
S5884	092	0		29	10	S5884_092_0	2	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	092	0		29	10	S5884_092_0	2	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	093	0		29	10	S5884_093_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	093	0		29	10	S5884_093_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	093	0		29	10	S5884_093_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				42	42		47	47		42					42	42		42	42		42	Non-Preferred Brand																								
S5884	094	0		29	10	S5884_094_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				45	45		50	50		45					45	45		45	45		45	Non-Preferred Brand																								
S5884	094	0		29	10	S5884_094_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				25	25		30	30		25					25	25		25	25		25	Non-Preferred Generics/Preferred Brand																								
S5884	094	0		29	10	S5884_094_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	1	Preferred Generic				15	15		20	20		15					0	0		15	15		15	Preferred Generic																								
S5884	095	0		29	10	S5884_095_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	095	0		29	10	S5884_095_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	095	0		29	10	S5884_095_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	095	0		29	10	S5884_095_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	097	0		29	10	S5884_097_0	1	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	097	0		29	10	S5884_097_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	097	0		29	10	S5884_097_0	1	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	097	0		29	10	S5884_097_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	099	0		29	10	S5884_099_0	2	4	4	1	Specialty	110110	1	1	2	Specialty	100010010010000100100				30			30			30					30			30			34		Specialty	1	Specialty				33			33			33					33			33			33	Specialty																								
S5884	099	0		29	10	S5884_099_0	2	4	4	3	Specialty	110110	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5884	099	0		29	10	S5884_099_0	2	2	4	3	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand																								Non-Preferred Generic/Preferred Brand		Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand																						2		
S5884	099	0		29	10	S5884_099_0	2	1	4	3	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00	1	1	
S5884	099	0		29	10	S5884_099_0	2	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand				75.00	225.00		80.00	240.00		75.00					75.00	187.50		75.00	225.00		75.00			
S5884	099	0		29	10	S5884_099_0	2	3	4	3	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5884	099	0		29	10	S5884_099_0	2	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				7.00	21.00		12.00	36.00		7.00					0.00	0.00		7.00	21.00		7.00			
S5884	099	0		29	10	S5884_099_0	2	2	4	1	Non-Preferred Generic/Preferred Brand	000111	1	2	2	Non-Preferred Generic/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generic/Preferred Brand	2	Non-Preferred Generic/Preferred Brand																						Non-Preferred Generic/Preferred Brand				45.00	135.00		50.00	150.00		45.00					45.00	112.50		45.00	135.00		45.00			
S5884	101	0		29	10	S5884_101_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	101	0		29	10	S5884_101_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	101	0		29	10	S5884_101_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				30	30		35	35		30					30	30		30	30		30	Non-Preferred Brand																								
S5884	102	0		29	10	S5884_102_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	102	0		29	10	S5884_102_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				35	35		40	40		35					35	35		35	35		35	Non-Preferred Brand																								
S5884	102	0		29	10	S5884_102_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	103	0		29	10	S5884_103_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				37	37		42	42		37					37	37		37	37		37	Non-Preferred Brand																								
S5884	103	0		29	10	S5884_103_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	103	0		29	10	S5884_103_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	104	0		29	10	S5884_104_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	104	0		29	10	S5884_104_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	104	0		29	10	S5884_104_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				36	36		41	41		36					36	36		36	36		36	Non-Preferred Brand																								
S5884	105	0		29	10	S5884_105_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				35	35		40	40		35					35	35		35	35		35	Non-Preferred Brand																								
S5884	105	0		29	10	S5884_105_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	105	0		29	10	S5884_105_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	106	0		29	10	S5884_106_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	106	0		29	10	S5884_106_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				33	33		38	38		33					33	33		33	33		33	Non-Preferred Brand																								
S5884	106	0		29	10	S5884_106_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	107	0		29	10	S5884_107_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	107	0		29	10	S5884_107_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				35	35		40	40		35					35	35		35	35		35	Non-Preferred Brand																								
S5884	107	0		29	10	S5884_107_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	108	0		29	10	S5884_108_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	108	0		29	10	S5884_108_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	108	0		29	10	S5884_108_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				32	32		37	37		32					32	32		32	32		32	Non-Preferred Brand																								
S5884	109	0		29	10	S5884_109_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	109	0		29	10	S5884_109_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				32	32		37	37		32					32	32		32	32		32	Non-Preferred Brand																								
S5884	109	0		29	10	S5884_109_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	110	0		29	10	S5884_110_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	110	0		29	10	S5884_110_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	110	0		29	10	S5884_110_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				33	33		38	38		33					33	33		33	33		33	Non-Preferred Brand																								
S5884	111	0		29	10	S5884_111_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	111	0		29	10	S5884_111_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	111	0		29	10	S5884_111_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				37	37		42	42		37					37	37		37	37		37	Non-Preferred Brand																								
S5884	112	0		29	10	S5884_112_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	112	0		29	10	S5884_112_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				34	34		39	39		34					34	34		34	34		34	Non-Preferred Brand																								
S5884	112	0		29	10	S5884_112_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	113	0		29	10	S5884_113_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				34	34		39	39		34					34	34		34	34		34	Non-Preferred Brand																								
S5884	113	0		29	10	S5884_113_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	113	0		29	10	S5884_113_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	114	0		29	10	S5884_114_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	114	0		29	10	S5884_114_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	114	0		29	10	S5884_114_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				36	36		41	41		36					36	36		36	36		36	Non-Preferred Brand																								
S5884	115	0		29	10	S5884_115_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	115	0		29	10	S5884_115_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	115	0		29	10	S5884_115_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				32	32		37	37		32					32	32		32	32		32	Non-Preferred Brand																								
S5884	116	0		29	10	S5884_116_0	1	3	4	1	Non-Preferred Brand	100010	1	2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				35	35		40	40		35					35	35		35	35		35	Non-Preferred Brand																								
S5884	116	0		29	10	S5884_116_0	1	2	4	1	Non-Preferred Generics/Preferred Brand	000111	1	2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	2	Non-Preferred Generics/Preferred Brand																						Non-Preferred Generics/Preferred Brand				35.00	105.00		40.00	120.00		35.00					35.00	87.50		35.00	105.00		35.00			
S5884	116	0		29	10	S5884_116_0	1	1	4	1	Preferred Generic	011000	1	2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				5.00	15.00		10.00	30.00		5.00					0.00	0.00		5.00	15.00		5.00			
S5884	118	0		29	10	S5884_118_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		9.00	27.00		4.00					0.00	0.00		4.00	12.00		4.00			
S5884	118	0		29	10	S5884_118_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Generics/Preferred Brand																								
S5884	118	0		29	10	S5884_118_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Brand																								
S5884	119	0		29	10	S5884_119_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		9.00	27.00		4.00					0.00	0.00		4.00	12.00		4.00			
S5884	119	0		29	10	S5884_119_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Generics/Preferred Brand																								
S5884	119	0		29	10	S5884_119_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Brand																								
S5884	121	0		29	10	S5884_121_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Brand																								
S5884	121	0		29	10	S5884_121_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		9.00	27.00		4.00					0.00	0.00		4.00	12.00		4.00			
S5884	121	0		29	10	S5884_121_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Generics/Preferred Brand																								
S5884	122	0		29	10	S5884_122_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Generics/Preferred Brand																								
S5884	122	0		29	10	S5884_122_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		9.00	27.00		4.00					0.00	0.00		4.00	12.00		4.00			
S5884	122	0		29	10	S5884_122_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Brand																								
S5884	123	0		29	10	S5884_123_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Brand																								
S5884	123	0		29	10	S5884_123_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		9.00	27.00		4.00					0.00	0.00		4.00	12.00		4.00			
S5884	123	0		29	10	S5884_123_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Generics/Preferred Brand																								
S5884	124	0		29	10	S5884_124_0	1	3	2	1	Non-Preferred Brand	100010		2	1	Non-Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	2	Non-Preferred Brand	1	Non-Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Brand																								
S5884	124	0		29	10	S5884_124_0	1	2	2	1	Non-Preferred Generics/Preferred Brand	000111		2	2	Non-Preferred Generics/Preferred Brand	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Non-Preferred Generics/Preferred Brand	1	Non-Preferred Generics/Preferred Brand				29	29		34	34		29					29	29		29	29		29	Non-Preferred Generics/Preferred Brand																								
S5884	124	0		29	10	S5884_124_0	1	1	2	1	Preferred Generic	011000		2	2	Preferred Generic	100011011010000110110				30	90		30	90		30					30	90		30	90		34	1	Preferred Generic	2	Preferred Generic																						Preferred Generic				4.00	12.00		9.00	27.00		4.00					0.00	0.00		4.00	12.00		4.00			
S5904	001	0		29	10	S5904_001_0	4	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
S5904	001	0		29	10	S5904_001_0	4	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
S5904	001	0		29	10	S5904_001_0	4	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
S5904	001	0		29	10	S5904_001_0	4	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	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	2	1	4	3	Tier 1 - Covered Generic	010000	1	2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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	1	1	
S5904	002	0		29	10	S5904_002_0	2	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																						2		
S5904	002	0		29	10	S5904_002_0	2	3	4	3	Tier 3 - Covered Brand	100000	1	2	1	Tier 3 - Covered Brand																								Tier 3 - Covered Brand		Tier 3 - Covered Brand																						Tier 3 - Covered Brand																						2		
S5904	002	0		29	10	S5904_002_0	2	4	4	1	Tier S - Covered Specialty	110001	1	1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	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	2	3	4	1	Tier 3 - Covered Brand	100000	1	2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
S5904	002	0		29	10	S5904_002_0	2	4	4	3	Tier S - Covered Specialty	110001	1	1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	33	33	33							33		33	33	33							33	Tier S - Covered Specialty																						1	2	01000000
S5904	002	0		29	10	S5904_002_0	2	1	4	1	Tier 1 - Covered Generic	010000	1	2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
S5904	002	0		29	10	S5904_002_0	2	2	4	1	Tier 2 - Covered Preferred Brand	000001	1	2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
S5904	003	0		29	10	S5904_003_0	2	3	3	1	Tier 3 - Covered Brand	100000		2	1	Tier 3 - Covered Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 3 - Covered Brand	2	Tier 3 - Covered Brand																						Tier 3 - Covered Brand	70.00	210.00	140.00							70.00		70.00	140.00	140.00							70.00			
S5904	003	0		29	10	S5904_003_0	2	4	3	1	Tier S - Covered Specialty	110001		1	2	Tier S - Covered Specialty	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier S - Covered Specialty	1	Tier S - Covered Specialty	25	25	25							25		25	25	25							25	Tier S - Covered Specialty																								
S5904	003	0		29	10	S5904_003_0	2	2	3	1	Tier 2 - Covered Preferred Brand	000001		2	2	Tier 2 - Covered Preferred Brand	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 2 - Covered Preferred Brand	2	Tier 2 - Covered Preferred Brand																						Tier 2 - Covered Preferred Brand	30.00	90.00	60.00							30.00		30.00	60.00	60.00							30.00			
S5904	003	0		29	10	S5904_003_0	2	1	3	1	Tier 1 - Covered Generic	010000		2	2	Tier 1 - Covered Generic	111100000010111000000	31	90	60							31		31	90	60							31	1	Tier 1 - Covered Generic	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			
S5907	001	0		29	10	S5907_001_0	2	3	2	1	Tier 3 / Nivel 3	000010		2	2	Tier 3 / Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3 / Nivel 3	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	2	4	2	1	Tier 4 / Nivel 4	100100		2	1	Tier 4 / Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4 / Nivel 4	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	2	5	2	1	Tier 5 / Nivel 5	010010		1	2	Tier 5 / Nivel 5	111100000010010000000	30	90	15							30			90								31	2	Tier 5 / Nivel 5	1	Tier 5 / Nivel 5	25	25	25							25			25								25	Tier 5 / Nivel 5																								
S5907	001	0		29	10	S5907_001_0	2	1	2	1	Tier 1 / Nivel 1	010000		2	2	Tier 1 / Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1 / Nivel 1	2	Tier 1 / Nivel 1																						Tier 1 / Nivel 1	6.00	18.00	6.00							6.00			18.00								6.00			
S5907	001	0		29	10	S5907_001_0	2	2	2	1	Tier 2 / Nivel 2	001001		2	2	Tier 2 / Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2 / Nivel 2	2	Tier 2 / Nivel 2																						Tier 2 / Nivel 2	21.00	63.00	21.00							21.00			63.00								21.00			
S5907	002	0		29	10	S5907_002_0	1	4	4	1	Tier 4 / Nivel 4	100100	1	2	1	Tier 4 / Nivel 4	111100000010010000000	30	90	15							30			90								31	2	Tier 4 / Nivel 4	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	1	3	4	1	Tier 3 / Nivel 3	000010	1	2	2	Tier 3 / Nivel 3	111100000010010000000	30	90	15							30			90								31	2	Tier 3 / Nivel 3	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	1	2	4	1	Tier 2 / Nivel 2	001001	1	2	2	Tier 2 / Nivel 2	111100000010010000000	30	90	15							30			90								31	2	Tier 2 / Nivel 2	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	1	1	4	1	Tier 1 / Nivel 1	010000	1	2	2	Tier 1 / Nivel 1	111100000010010000000	30	90	15							30			90								31	2	Tier 1 / Nivel 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	1	5	4	1	Tier 5 / Nivel 5	010010	1	1	2	Tier 5 / Nivel 5	111100000010010000000	30	90	15							30			90								31	2	Tier 5 / Nivel 5	1	Tier 5 / Nivel 5	25	25	25							25			25								25	Tier 5 / Nivel 5																								
S5915	002	0		29	10	S5915_002_0	5	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
S5915	002	0		29	10	S5915_002_0	5	3	4	3	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic																								Non-Preferred Brand or Generic		Non-Preferred Brand or Generic																						Non-Preferred Brand or Generic																						2		
S5915	002	0		29	10	S5915_002_0	5	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5915	002	0		29	10	S5915_002_0	5	4	4	3	Specialty	111111	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5915	002	0		29	10	S5915_002_0	5	1	4	3	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	4.00	12.00	8.00							4.00		4.00	8.00								4.00	1	1	
S5915	002	0		29	10	S5915_002_0	5	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	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	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	5	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	003	0		29	10	S5915_003_0	5	3	3	1	Non-Preferred Brand or Generic	100100		2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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			
S5915	003	0		29	10	S5915_003_0	5	1	3	1	Preferred Generic	001000		2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	1.00	3.00	2.00							1.00		1.00	2.00								1.00			
S5915	003	0		29	10	S5915_003_0	5	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	29.00	87.00	58.00							29.00		29.00	58.00								29.00			
S5915	004	0		29	10	S5915_004_0	5	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Brand	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	1	4	1	Preferred Generic	001000	1	2	2	Preferred Generic	111100000010110000000	30	90	60							30		30	90								34	2	Preferred Generic	2	Preferred Generic																						Preferred Generic	6.00	18.00	12.00							6.00		6.00	12.00								6.00			
S5915	004	0		29	10	S5915_004_0	5	3	4	1	Non-Preferred Brand or Generic	100100	1	2	1	Non-Preferred Brand or Generic	111100000010110000000	30	90	60							30		30	90								34	2	Non-Preferred Brand or Generic	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	4	4	1	Specialty	111111	1	1	2	Specialty	111100000010110000000	30	90	60							30		30	90								34	2	Specialty	1	Specialty	33	33	33							33		33	33								33	Specialty																								
S5916	001	0		29	10	S5916_001_0	4	5	3	1	Specialty	110001		1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	27									27		27									27	Specialty																								
S5916	001	0		29	10	S5916_001_0	4	4	3	1	Miscellaneous Injectables	110001		2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	27									27		27									27	Miscellaneous Injectables																								
S5916	001	0		29	10	S5916_001_0	4	3	3	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	61.00	183.00								61.00		61.00	183.00								61.00			
S5916	001	0		29	10	S5916_001_0	4	1	3	1	Generic	001000		2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
S5916	001	0		29	10	S5916_001_0	4	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
S5916	002	0		29	10	S5916_002_0	3	5	4	1	Specialty	110001	1	1	2	Specialty	110000000010100000000	30									30		30									31		Specialty	1	Specialty	30									30		30									30	Specialty																								
S5916	002	0		29	10	S5916_002_0	3	4	4	1	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables	110000000010100000000	30									30		30									31		Miscellaneous Injectables	1	Miscellaneous Injectables	30									30		30									30	Miscellaneous Injectables																								
S5916	002	0		29	10	S5916_002_0	3	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5916	002	0		29	10	S5916_002_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5916	002	0		29	10	S5916_002_0	3	4	4	3	Miscellaneous Injectables	110001	1	2	2	Miscellaneous Injectables																								Miscellaneous Injectables		Miscellaneous Injectables																						Miscellaneous Injectables																						2		
S5916	002	0		29	10	S5916_002_0	3	5	4	3	Specialty	110001	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5916	002	0		29	10	S5916_002_0	3	1	4	3	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00	1	1	
S5916	002	0		29	10	S5916_002_0	3	1	4	1	Generic	001000	1	2	2	Generic	111000000010110000000	30	90								30		30	90								31	1	Generic	2	Generic																						Generic	4.00	12.00								4.00		4.00	12.00								4.00			
S5916	002	0		29	10	S5916_002_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
S5916	002	0		29	10	S5916_002_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010110000000	30	90								30		30	90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	56.00	168.00								56.00		56.00	168.00								56.00			
S5917	001	0		29	10	S5917_001_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5917	001	0		29	10	S5917_001_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	70.00	210.00								70.00						195.00			210.00		70.00			
S5917	001	0		29	10	S5917_001_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5917	001	0		29	10	S5917_001_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5917	002	0		29	10	S5917_002_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5917	002	0		29	10	S5917_002_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5917	002	0		29	10	S5917_002_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	8.00	24.00								8.00						4.00			24.00		8.00			
S5917	002	0		29	10	S5917_002_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						120.00			135.00		45.00			
S5917	003	0		29	10	S5917_003_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5917	003	0		29	10	S5917_003_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	30.00	90.00								30.00						75.00			90.00		30.00			
S5917	003	0		29	10	S5917_003_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	70.00	210.00								70.00						195.00			210.00		70.00			
S5917	003	0		29	10	S5917_003_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5917	005	0		29	10	S5917_005_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5917	005	0		29	10	S5917_005_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	9.00	27.00								9.00						4.00			27.00		9.00			
S5917	005	0		29	10	S5917_005_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	45.00	135.00								45.00						120.00			135.00		45.00			
S5917	005	0		29	10	S5917_005_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5917	007	0		29	10	S5917_007_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5917	007	0		29	10	S5917_007_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						225.00			240.00		80.00			
S5917	007	0		29	10	S5917_007_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5917	007	0		29	10	S5917_007_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	001	0		29	10	S5921_001_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.25	240.75								80.25						225.75			240.75		80.25			
S5921	001	0		29	10	S5921_001_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	001	0		29	10	S5921_001_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	001	0		29	10	S5921_001_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	003	0		29	10	S5921_003_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	003	0		29	10	S5921_003_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	003	0		29	10	S5921_003_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	003	0		29	10	S5921_003_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	003	0		29	10	S5921_003_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	003	0		29	10	S5921_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																						2		
S5921	003	0		29	10	S5921_003_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	003	0		29	10	S5921_003_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	011	0		29	10	S5921_011_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	61.00	183.00								61.00						168.00			183.00		61.00			
S5921	011	0		29	10	S5921_011_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	011	0		29	10	S5921_011_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	011	0		29	10	S5921_011_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	013	0		29	10	S5921_013_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	013	0		29	10	S5921_013_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	013	0		29	10	S5921_013_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	013	0		29	10	S5921_013_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	013	0		29	10	S5921_013_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	013	0		29	10	S5921_013_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	013	0		29	10	S5921_013_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	013	0		29	10	S5921_013_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	021	0		29	10	S5921_021_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	021	0		29	10	S5921_021_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	021	0		29	10	S5921_021_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	021	0		29	10	S5921_021_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	78.50	235.50								78.50						220.50			235.50		78.50			
S5921	023	0		29	10	S5921_023_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	023	0		29	10	S5921_023_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	023	0		29	10	S5921_023_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	023	0		29	10	S5921_023_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	023	0		29	10	S5921_023_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	023	0		29	10	S5921_023_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	023	0		29	10	S5921_023_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	023	0		29	10	S5921_023_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	031	0		29	10	S5921_031_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	031	0		29	10	S5921_031_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	83.00	249.00								83.00						234.00			249.00		83.00			
S5921	031	0		29	10	S5921_031_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	031	0		29	10	S5921_031_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	033	0		29	10	S5921_033_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	033	0		29	10	S5921_033_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	033	0		29	10	S5921_033_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	033	0		29	10	S5921_033_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	033	0		29	10	S5921_033_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	033	0		29	10	S5921_033_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	033	0		29	10	S5921_033_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	033	0		29	10	S5921_033_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	041	0		29	10	S5921_041_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	86.00	258.00								86.00						243.00			258.00		86.00			
S5921	041	0		29	10	S5921_041_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	041	0		29	10	S5921_041_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	041	0		29	10	S5921_041_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	043	0		29	10	S5921_043_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	043	0		29	10	S5921_043_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	043	0		29	10	S5921_043_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	043	0		29	10	S5921_043_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	043	0		29	10	S5921_043_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	043	0		29	10	S5921_043_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	043	0		29	10	S5921_043_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	043	0		29	10	S5921_043_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	051	0		29	10	S5921_051_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	81.75	245.25								81.75						230.25			245.25		81.75			
S5921	051	0		29	10	S5921_051_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	051	0		29	10	S5921_051_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	051	0		29	10	S5921_051_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	053	0		29	10	S5921_053_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	053	0		29	10	S5921_053_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	053	0		29	10	S5921_053_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	053	0		29	10	S5921_053_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	053	0		29	10	S5921_053_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	053	0		29	10	S5921_053_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	053	0		29	10	S5921_053_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	053	0		29	10	S5921_053_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	061	0		29	10	S5921_061_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	77.25	231.75								77.25						216.75			231.75		77.25			
S5921	061	0		29	10	S5921_061_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	061	0		29	10	S5921_061_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	061	0		29	10	S5921_061_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	063	0		29	10	S5921_063_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	063	0		29	10	S5921_063_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	063	0		29	10	S5921_063_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	063	0		29	10	S5921_063_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	063	0		29	10	S5921_063_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	063	0		29	10	S5921_063_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	063	0		29	10	S5921_063_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	063	0		29	10	S5921_063_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	071	0		29	10	S5921_071_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.25	255.75								85.25						240.75			255.75		85.25			
S5921	071	0		29	10	S5921_071_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	071	0		29	10	S5921_071_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	071	0		29	10	S5921_071_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	073	0		29	10	S5921_073_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	073	0		29	10	S5921_073_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	073	0		29	10	S5921_073_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	073	0		29	10	S5921_073_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	073	0		29	10	S5921_073_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	073	0		29	10	S5921_073_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	073	0		29	10	S5921_073_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	073	0		29	10	S5921_073_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	081	0		29	10	S5921_081_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	081	0		29	10	S5921_081_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	081	0		29	10	S5921_081_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	081	0		29	10	S5921_081_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	65.00	195.00								65.00						180.00			195.00		65.00			
S5921	083	0		29	10	S5921_083_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	083	0		29	10	S5921_083_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	083	0		29	10	S5921_083_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	083	0		29	10	S5921_083_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	083	0		29	10	S5921_083_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	083	0		29	10	S5921_083_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	083	0		29	10	S5921_083_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	083	0		29	10	S5921_083_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	091	0		29	10	S5921_091_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	091	0		29	10	S5921_091_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	091	0		29	10	S5921_091_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	091	0		29	10	S5921_091_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	82.75	248.25								82.75						233.25			248.25		82.75			
S5921	093	0		29	10	S5921_093_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	093	0		29	10	S5921_093_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	093	0		29	10	S5921_093_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	093	0		29	10	S5921_093_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	093	0		29	10	S5921_093_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	093	0		29	10	S5921_093_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	093	0		29	10	S5921_093_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	093	0		29	10	S5921_093_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	101	0		29	10	S5921_101_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	101	0		29	10	S5921_101_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	101	0		29	10	S5921_101_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	83.00	249.00								83.00						234.00			249.00		83.00			
S5921	101	0		29	10	S5921_101_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	103	0		29	10	S5921_103_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	103	0		29	10	S5921_103_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	103	0		29	10	S5921_103_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	103	0		29	10	S5921_103_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	103	0		29	10	S5921_103_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	103	0		29	10	S5921_103_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	103	0		29	10	S5921_103_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	103	0		29	10	S5921_103_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	111	0		29	10	S5921_111_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	111	0		29	10	S5921_111_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	83.00	249.00								83.00						234.00			249.00		83.00			
S5921	111	0		29	10	S5921_111_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	111	0		29	10	S5921_111_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	113	0		29	10	S5921_113_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	113	0		29	10	S5921_113_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	113	0		29	10	S5921_113_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	113	0		29	10	S5921_113_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	113	0		29	10	S5921_113_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	113	0		29	10	S5921_113_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	113	0		29	10	S5921_113_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	113	0		29	10	S5921_113_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	121	0		29	10	S5921_121_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	76.50	229.50								76.50						214.50			229.50		76.50			
S5921	121	0		29	10	S5921_121_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	121	0		29	10	S5921_121_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	121	0		29	10	S5921_121_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	123	0		29	10	S5921_123_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	123	0		29	10	S5921_123_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	123	0		29	10	S5921_123_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	123	0		29	10	S5921_123_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	123	0		29	10	S5921_123_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	123	0		29	10	S5921_123_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	123	0		29	10	S5921_123_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	123	0		29	10	S5921_123_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	131	0		29	10	S5921_131_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	131	0		29	10	S5921_131_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	131	0		29	10	S5921_131_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	76.50	229.50								76.50						214.50			229.50		76.50			
S5921	131	0		29	10	S5921_131_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	133	0		29	10	S5921_133_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	133	0		29	10	S5921_133_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	133	0		29	10	S5921_133_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	133	0		29	10	S5921_133_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	133	0		29	10	S5921_133_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	133	0		29	10	S5921_133_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	133	0		29	10	S5921_133_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	133	0		29	10	S5921_133_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	141	0		29	10	S5921_141_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	82.75	248.25								82.75						233.25			248.25		82.75			
S5921	141	0		29	10	S5921_141_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	141	0		29	10	S5921_141_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	141	0		29	10	S5921_141_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	143	0		29	10	S5921_143_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	143	0		29	10	S5921_143_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	143	0		29	10	S5921_143_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	143	0		29	10	S5921_143_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	143	0		29	10	S5921_143_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	143	0		29	10	S5921_143_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	143	0		29	10	S5921_143_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	143	0		29	10	S5921_143_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	151	0		29	10	S5921_151_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	151	0		29	10	S5921_151_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	71.50	214.50								71.50						199.50			214.50		71.50			
S5921	151	0		29	10	S5921_151_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	151	0		29	10	S5921_151_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	153	0		29	10	S5921_153_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	153	0		29	10	S5921_153_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	153	0		29	10	S5921_153_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	153	0		29	10	S5921_153_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	153	0		29	10	S5921_153_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	153	0		29	10	S5921_153_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	153	0		29	10	S5921_153_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	153	0		29	10	S5921_153_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	161	0		29	10	S5921_161_0	3	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	95.00	285.00								95.00						270.00			285.00		95.00			
S5921	161	0		29	10	S5921_161_0	3	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	161	0		29	10	S5921_161_0	3	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	161	0		29	10	S5921_161_0	3	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	163	0		29	10	S5921_163_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	163	0		29	10	S5921_163_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	163	0		29	10	S5921_163_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	163	0		29	10	S5921_163_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	163	0		29	10	S5921_163_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	163	0		29	10	S5921_163_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	163	0		29	10	S5921_163_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	163	0		29	10	S5921_163_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	171	0		29	10	S5921_171_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						225.00			240.00		80.00			
S5921	171	0		29	10	S5921_171_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	171	0		29	10	S5921_171_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	171	0		29	10	S5921_171_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	173	0		29	10	S5921_173_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	173	0		29	10	S5921_173_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	173	0		29	10	S5921_173_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	173	0		29	10	S5921_173_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	173	0		29	10	S5921_173_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	173	0		29	10	S5921_173_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	173	0		29	10	S5921_173_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	173	0		29	10	S5921_173_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	181	0		29	10	S5921_181_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	181	0		29	10	S5921_181_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.25	240.75								80.25						225.75			240.75		80.25			
S5921	181	0		29	10	S5921_181_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	181	0		29	10	S5921_181_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	183	0		29	10	S5921_183_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	183	0		29	10	S5921_183_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	183	0		29	10	S5921_183_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	183	0		29	10	S5921_183_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	183	0		29	10	S5921_183_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	183	0		29	10	S5921_183_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	183	0		29	10	S5921_183_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	183	0		29	10	S5921_183_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	191	0		29	10	S5921_191_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	80.00	240.00								80.00						225.00			240.00		80.00			
S5921	191	0		29	10	S5921_191_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	191	0		29	10	S5921_191_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	191	0		29	10	S5921_191_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	193	0		29	10	S5921_193_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	193	0		29	10	S5921_193_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	193	0		29	10	S5921_193_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	193	0		29	10	S5921_193_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	193	0		29	10	S5921_193_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	193	0		29	10	S5921_193_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	193	0		29	10	S5921_193_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	193	0		29	10	S5921_193_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	201	0		29	10	S5921_201_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	201	0		29	10	S5921_201_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	201	0		29	10	S5921_201_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	77.00	231.00								77.00						216.00			231.00		77.00			
S5921	201	0		29	10	S5921_201_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	203	0		29	10	S5921_203_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	203	0		29	10	S5921_203_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	203	0		29	10	S5921_203_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	93.00	279.00								93.00						264.00			279.00		93.00			
S5921	203	0		29	10	S5921_203_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	213	0		29	10	S5921_213_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	213	0		29	10	S5921_213_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	213	0		29	10	S5921_213_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	213	0		29	10	S5921_213_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	213	0		29	10	S5921_213_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	213	0		29	10	S5921_213_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	213	0		29	10	S5921_213_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	213	0		29	10	S5921_213_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	221	0		29	10	S5921_221_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	221	0		29	10	S5921_221_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	221	0		29	10	S5921_221_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	221	0		29	10	S5921_221_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	86.00	258.00								86.00						243.00			258.00		86.00			
S5921	223	0		29	10	S5921_223_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	223	0		29	10	S5921_223_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	223	0		29	10	S5921_223_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	223	0		29	10	S5921_223_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	223	0		29	10	S5921_223_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	223	0		29	10	S5921_223_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	223	0		29	10	S5921_223_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	223	0		29	10	S5921_223_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	231	0		29	10	S5921_231_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	75.25	225.75								75.25						210.75			225.75		75.25			
S5921	231	0		29	10	S5921_231_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	231	0		29	10	S5921_231_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	231	0		29	10	S5921_231_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	233	0		29	10	S5921_233_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	233	0		29	10	S5921_233_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	233	0		29	10	S5921_233_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	233	0		29	10	S5921_233_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	233	0		29	10	S5921_233_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	233	0		29	10	S5921_233_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	233	0		29	10	S5921_233_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	233	0		29	10	S5921_233_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	235	0		29	10	S5921_235_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	235	0		29	10	S5921_235_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	235	0		29	10	S5921_235_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	235	0		29	10	S5921_235_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	235	0		29	10	S5921_235_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	235	0		29	10	S5921_235_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	235	0		29	10	S5921_235_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	235	0		29	10	S5921_235_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	237	0		29	10	S5921_237_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	237	0		29	10	S5921_237_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	237	0		29	10	S5921_237_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	92.50	277.50								92.50						262.50			277.50		92.50			
S5921	237	0		29	10	S5921_237_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	239	0		29	10	S5921_239_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	239	0		29	10	S5921_239_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	239	0		29	10	S5921_239_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	239	0		29	10	S5921_239_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	239	0		29	10	S5921_239_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	239	0		29	10	S5921_239_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	239	0		29	10	S5921_239_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	239	0		29	10	S5921_239_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	247	0		29	10	S5921_247_0	3	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	247	0		29	10	S5921_247_0	3	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	247	0		29	10	S5921_247_0	3	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	247	0		29	10	S5921_247_0	3	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	95.00	285.00								95.00						270.00			285.00		95.00			
S5921	249	0		29	10	S5921_249_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	249	0		29	10	S5921_249_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	249	0		29	10	S5921_249_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	249	0		29	10	S5921_249_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	249	0		29	10	S5921_249_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	249	0		29	10	S5921_249_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	249	0		29	10	S5921_249_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	249	0		29	10	S5921_249_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	261	0		29	10	S5921_261_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	261	0		29	10	S5921_261_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	261	0		29	10	S5921_261_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	72.00	216.00								72.00						201.00			216.00		72.00			
S5921	261	0		29	10	S5921_261_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	263	0		29	10	S5921_263_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	263	0		29	10	S5921_263_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	263	0		29	10	S5921_263_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	263	0		29	10	S5921_263_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	263	0		29	10	S5921_263_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	263	0		29	10	S5921_263_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	263	0		29	10	S5921_263_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	263	0		29	10	S5921_263_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	265	0		29	10	S5921_265_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	265	0		29	10	S5921_265_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	265	0		29	10	S5921_265_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	84.75	254.25								84.75						239.25			254.25		84.75			
S5921	265	0		29	10	S5921_265_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	273	0		29	10	S5921_273_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	273	0		29	10	S5921_273_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	273	0		29	10	S5921_273_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	273	0		29	10	S5921_273_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	273	0		29	10	S5921_273_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	273	0		29	10	S5921_273_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	273	0		29	10	S5921_273_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	273	0		29	10	S5921_273_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	281	0		29	10	S5921_281_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	281	0		29	10	S5921_281_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	81.75	245.25								81.75						230.25			245.25		81.75			
S5921	281	0		29	10	S5921_281_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	281	0		29	10	S5921_281_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	283	0		29	10	S5921_283_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	283	0		29	10	S5921_283_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	283	0		29	10	S5921_283_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	283	0		29	10	S5921_283_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	283	0		29	10	S5921_283_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	283	0		29	10	S5921_283_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	283	0		29	10	S5921_283_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	283	0		29	10	S5921_283_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	286	0		29	10	S5921_286_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	286	0		29	10	S5921_286_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	286	0		29	10	S5921_286_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	82.75	248.25								82.75						233.25			248.25		82.75			
S5921	286	0		29	10	S5921_286_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	293	0		29	10	S5921_293_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	293	0		29	10	S5921_293_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	293	0		29	10	S5921_293_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	293	0		29	10	S5921_293_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	293	0		29	10	S5921_293_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	293	0		29	10	S5921_293_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	293	0		29	10	S5921_293_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	293	0		29	10	S5921_293_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	301	0		29	10	S5921_301_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	81.00	243.00								81.00						228.00			243.00		81.00			
S5921	301	0		29	10	S5921_301_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	301	0		29	10	S5921_301_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	301	0		29	10	S5921_301_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	303	0		29	10	S5921_303_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	303	0		29	10	S5921_303_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	303	0		29	10	S5921_303_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	303	0		29	10	S5921_303_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	303	0		29	10	S5921_303_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	303	0		29	10	S5921_303_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	303	0		29	10	S5921_303_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	303	0		29	10	S5921_303_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	311	0		29	10	S5921_311_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	311	0		29	10	S5921_311_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	311	0		29	10	S5921_311_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	85.00	255.00								85.00						240.00			255.00		85.00			
S5921	311	0		29	10	S5921_311_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	313	0		29	10	S5921_313_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	313	0		29	10	S5921_313_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	313	0		29	10	S5921_313_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	313	0		29	10	S5921_313_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	313	0		29	10	S5921_313_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	313	0		29	10	S5921_313_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	313	0		29	10	S5921_313_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	313	0		29	10	S5921_313_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	321	0		29	10	S5921_321_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	321	0		29	10	S5921_321_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	321	0		29	10	S5921_321_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	71.75	215.25								71.75						200.25			215.25		71.75			
S5921	321	0		29	10	S5921_321_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	323	0		29	10	S5921_323_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	323	0		29	10	S5921_323_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	323	0		29	10	S5921_323_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5921	323	0		29	10	S5921_323_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	323	0		29	10	S5921_323_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	323	0		29	10	S5921_323_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	323	0		29	10	S5921_323_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	323	0		29	10	S5921_323_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	331	0		29	10	S5921_331_0	2	4	2	1	Tier 4 Specialty	010010		1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	25	25								25						25			25		25	Tier 4 Specialty																								
S5921	331	0		29	10	S5921_331_0	2	2	2	1	Tier 2 Generic  Preferred Brand	010101		2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	25.00	75.00								25.00						60.00			75.00		25.00			
S5921	331	0		29	10	S5921_331_0	2	3	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100		2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	70.50	211.50								70.50						196.50			211.50		70.50			
S5921	331	0		29	10	S5921_331_0	2	1	2	1	Tier 1 Preferred Generic  Brand	001001		2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	6.00	18.00								6.00						4.00			18.00		6.00			
S5921	333	0		29	10	S5921_333_0	2	1	4	3	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	14.00	42.00								14.00						14.00			42.00		14.00	1	1	
S5921	333	0		29	10	S5921_333_0	2	3	4	3	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	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																						2		
S5921	333	0		29	10	S5921_333_0	2	4	4	3	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty																								Tier 4 Specialty		Tier 4 Specialty																						Tier 4 Specialty																						2		
S5921	333	0		29	10	S5921_333_0	2	1	4	1	Tier 1 Preferred Generic  Brand	001001	1	2	2	Tier 1 Preferred Generic  Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 1 Preferred Generic  Brand	2	Tier 1 Preferred Generic  Brand																						Tier 1 Preferred Generic  Brand	7.00	21.00								7.00						4.00			21.00		7.00			
S5921	333	0		29	10	S5921_333_0	2	2	4	1	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 2 Generic  Preferred Brand	2	Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand	42.00	126.00								42.00						111.00			126.00		42.00			
S5921	333	0		29	10	S5921_333_0	2	3	4	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	100100	1	2	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Tier 3 Non-Preferred Generic  Non-Preferred Brand	2	Tier 3 Non-Preferred Generic  Non-Preferred Brand																						Tier 3 Non-Preferred Generic  Non-Preferred Brand	90.00	270.00								90.00						255.00			270.00		90.00			
S5921	333	0		29	10	S5921_333_0	2	4	4	1	Tier 4 Specialty	010010	1	1	2	Tier 4 Specialty	111000000010000010010	31	90								31						90			90		31	1	Tier 4 Specialty	1	Tier 4 Specialty	33	33								33						33			33		33	Tier 4 Specialty																								
S5921	333	0		29	10	S5921_333_0	2	2	4	3	Tier 2 Generic  Preferred Brand	010101	1	2	2	Tier 2 Generic  Preferred Brand																								Tier 2 Generic  Preferred Brand		Tier 2 Generic  Preferred Brand																						Tier 2 Generic  Preferred Brand																						2		
S5937	001	0		29	10	S5937_001_0	5	1	3	1	Generic	010000		2	2	Generic	111000000010110000000	34	90								34		34	90								34	1	Generic	2	Generic																						Generic	5.00	15.00								5.00		5.00	15.00								5.00			
S5937	001	0		29	10	S5937_001_0	5	4	3	1	Specialty	010010		1	2	Specialty	111000000010110000000	34	90								34		34	90								34	1	Specialty	1	Specialty	31	31								31		31	31								31	Specialty																								
S5937	001	0		29	10	S5937_001_0	5	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	70.00	210.00								70.00		70.00	210.00								70.00			
S5937	001	0		29	10	S5937_001_0	5	2	3	1	Preferred Brand	000001		2	1	Preferred Brand	111000000010110000000	34	90								34		34	90								34	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	30.00	90.00								30.00		30.00	90.00								30.00			
S5953	001	0		29	10	S5953_001_0	2	3	3	1	Non-Preferred Brand	100000		2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	78.00	234.00								78.00						195.00			234.00		78.00			
S5953	001	0		29	10	S5953_001_0	2	2	3	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	44.00	132.00								44.00						110.00			132.00		44.00			
S5953	001	0		29	10	S5953_001_0	2	1	3	1	Generics	010000		2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	8.00	24.00								8.00						20.00			24.00		8.00			
S5953	001	0		29	10	S5953_001_0	2	4	3	1	Specialty	010010		1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5953	002	0		29	10	S5953_002_0	2	5	4	1	Specialty	010010	1	1	1	Specialty	111000000010000010010	31	90								31						90			90		31	1	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5953	002	0		29	10	S5953_002_0	2	1	4	3	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	2.00	6.00								2.00						4.00			6.00		2.00	1	1	
S5953	002	0		29	10	S5953_002_0	2	3	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5953	002	0		29	10	S5953_002_0	2	4	4	3	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5953	002	0		29	10	S5953_002_0	2	5	4	3	Specialty	010010	1	1	1	Specialty																								Specialty		Specialty																						Specialty																						2		
S5953	002	0		29	10	S5953_002_0	2	4	4	1	Non-Preferred Brand	100000	1	2	2	Non-Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	75.00	225.00								75.00						187.50			225.00		75.00			
S5953	002	0		29	10	S5953_002_0	2	3	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	31	90								31						90			90		31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5953	002	0		29	10	S5953_002_0	2	2	4	1	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	9.00	27.00								9.00						22.50			27.00		9.00			
S5953	002	0		29	10	S5953_002_0	2	1	4	1	Value Generics	010000	1	2	2	Value Generics	111000000010000010010	31	90								31						90			90		31	1	Value Generics	2	Value Generics																						Value Generics	2.00	6.00								2.00						4.00			6.00		2.00			
S5953	002	0		29	10	S5953_002_0	2	2	4	3	Generics	010000	1	2	2	Generics	111000000010000010010	31	90								31						90			90		31	1	Generics	2	Generics																						Generics	9.00	27.00								9.00						22.50			27.00		9.00	1	1	
S5954	004	0		29	10	S5954_004_0	1	1	2	1	Tier 1	001001		2	2	Tier 1	111000000001010000000	30	90									10		90								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	8.00									4.00		8.00								4.00			
S5954	004	0		29	10	S5954_004_0	1	2	2	1	Tier 2	001001		2	1	Tier 2	111000000001010000000	30	90									10		90								31	1	Tier 2	2	Tier 2																						Tier 2	47.00	94.00									47.00		94.00								47.00			
S5954	004	0		29	10	S5954_004_0	1	3	2	1	Tier 3	010010		1	2	Tier 3	111000000001010000000	30	90									10		90								31	2	Tier 3	1	Tier 3	25	25									25		25								25	Tier 3																								
S5954	005	0		29	10	S5954_005_0	1	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000001010000000	30	90									10		90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	10.00									5.00		10.00								5.00			
S5954	005	0		29	10	S5954_005_0	1	2	4	1	Tier 2	001001	1	2	2	Tier 2	111000000001010000000	30	90									10		90								31	1	Tier 2	2	Tier 2																						Tier 2	37.00	74.00									37.00		74.00								37.00			
S5954	005	0		29	10	S5954_005_0	1	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000001010000000	30	90									10		90								31	1	Tier 3	2	Tier 3																						Tier 3	72.00	144.00									72.00		144.00								72.00			
S5954	005	0		29	10	S5954_005_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001010000000	30	90									10		90								31	2	Tier 4	1	Tier 4	33	33									33		33								33	Tier 4																								
S5954	005	0		29	10	S5954_005_0	1	1	4	3	Tier 1	001001	1	2	2	Tier 1	111000000001010000000	30	90									10		90								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	10.00									5.00		10.00								5.00	1	1	
S5954	005	0		29	10	S5954_005_0	1	2	4	3	Tier 2	001001	1	2	2	Tier 2																								Tier 2		Tier 2																						Tier 2																						2		
S5954	005	0		29	10	S5954_005_0	1	4	4	3	Tier 4	010010	1	1	2	Tier 4																								Tier 4		Tier 4																						Tier 4																						2		
S5954	005	0		29	10	S5954_005_0	1	3	4	3	Tier 3	100100	1	2	1	Tier 3																								Tier 3		Tier 3																						Tier 3																						2		
S5954	007	0		29	10	S5954_007_0	1	1	4	1	Tier 1	001001	1	2	2	Tier 1	111000000001010000000	30	90									10		90								31	1	Tier 1	2	Tier 1																						Tier 1	6.00	12.00									6.00		12.00								6.00			
S5954	007	0		29	10	S5954_007_0	1	3	4	1	Tier 3	100100	1	2	1	Tier 3	111000000001010000000	30	90									10		90								31	1	Tier 3	2	Tier 3																						Tier 3	84.00	168.00									84.00		168.00								84.00			
S5954	007	0		29	10	S5954_007_0	1	2	4	1	Tier 2	001001	1	2	2	Tier 2	111000000001010000000	30	90									10		90								31	1	Tier 2	2	Tier 2																						Tier 2	34.00	68.00									34.00		68.00								34.00			
S5954	007	0		29	10	S5954_007_0	1	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000001010000000	30	90									10		90								31	2	Tier 4	1	Tier 4	33	33									33		33								33	Tier 4																								
S5960	108	0		29	10	S5960_108_0	5	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	108	0		29	10	S5960_108_0	5	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	108	0		29	10	S5960_108_0	5	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	108	0		29	10	S5960_108_0	5	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	109	0		29	10	S5960_109_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	109	0		29	10	S5960_109_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	109	0		29	10	S5960_109_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	109	0		29	10	S5960_109_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	110	0		29	10	S5960_110_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	110	0		29	10	S5960_110_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	110	0		29	10	S5960_110_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	110	0		29	10	S5960_110_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	8.00	24.00								8.00						12.00			24.00		8.00			
S5960	111	0		29	10	S5960_111_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	111	0		29	10	S5960_111_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	111	0		29	10	S5960_111_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	111	0		29	10	S5960_111_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	112	0		29	10	S5960_112_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	112	0		29	10	S5960_112_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	112	0		29	10	S5960_112_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	112	0		29	10	S5960_112_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	114	0		29	10	S5960_114_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	114	0		29	10	S5960_114_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	114	0		29	10	S5960_114_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	114	0		29	10	S5960_114_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	115	0		29	10	S5960_115_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	115	0		29	10	S5960_115_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	115	0		29	10	S5960_115_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	115	0		29	10	S5960_115_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	117	0		29	10	S5960_117_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	117	0		29	10	S5960_117_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	117	0		29	10	S5960_117_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	117	0		29	10	S5960_117_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	118	0		29	10	S5960_118_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	118	0		29	10	S5960_118_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	118	0		29	10	S5960_118_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	118	0		29	10	S5960_118_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	119	0		29	10	S5960_119_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	119	0		29	10	S5960_119_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	119	0		29	10	S5960_119_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	119	0		29	10	S5960_119_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	123	0		29	10	S5960_123_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	123	0		29	10	S5960_123_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	123	0		29	10	S5960_123_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	123	0		29	10	S5960_123_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	125	0		29	10	S5960_125_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	5.50	16.50								5.50						8.25			16.50		5.50			
S5960	125	0		29	10	S5960_125_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	125	0		29	10	S5960_125_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	125	0		29	10	S5960_125_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	126	0		29	10	S5960_126_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	126	0		29	10	S5960_126_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	126	0		29	10	S5960_126_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	126	0		29	10	S5960_126_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	127	0		29	10	S5960_127_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	127	0		29	10	S5960_127_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	127	0		29	10	S5960_127_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	127	0		29	10	S5960_127_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	128	0		29	10	S5960_128_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	128	0		29	10	S5960_128_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	128	0		29	10	S5960_128_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	128	0		29	10	S5960_128_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	129	0		29	10	S5960_129_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	129	0		29	10	S5960_129_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	129	0		29	10	S5960_129_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	129	0		29	10	S5960_129_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	130	0		29	10	S5960_130_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	130	0		29	10	S5960_130_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	130	0		29	10	S5960_130_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	130	0		29	10	S5960_130_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	131	0		29	10	S5960_131_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	131	0		29	10	S5960_131_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	131	0		29	10	S5960_131_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	131	0		29	10	S5960_131_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	132	0		29	10	S5960_132_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	132	0		29	10	S5960_132_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	132	0		29	10	S5960_132_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	132	0		29	10	S5960_132_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	134	0		29	10	S5960_134_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	134	0		29	10	S5960_134_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	134	0		29	10	S5960_134_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	134	0		29	10	S5960_134_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	136	0		29	10	S5960_136_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	136	0		29	10	S5960_136_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	136	0		29	10	S5960_136_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	136	0		29	10	S5960_136_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	137	0		29	10	S5960_137_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	137	0		29	10	S5960_137_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	137	0		29	10	S5960_137_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	137	0		29	10	S5960_137_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	139	0		29	10	S5960_139_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.50	19.50								6.50						9.75			19.50		6.50			
S5960	139	0		29	10	S5960_139_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	139	0		29	10	S5960_139_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	139	0		29	10	S5960_139_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	140	0		29	10	S5960_140_0	3	4	2	1	Tier 4 Specialty Drugs	010010		1	2	Tier 4 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 4 Specialty Drugs	1	Tier 4 Specialty Drugs	25									25					25			25			25	Tier 4 Specialty Drugs																								
S5960	140	0		29	10	S5960_140_0	3	3	2	1	Tier 3 Non-Specialty Injectable Drugs	010010		2	2	Tier 3 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Specialty Injectable Drugs	1	Tier 3 Non-Specialty Injectable Drugs	25	25								25						25			25		25	Tier 3 Non-Specialty Injectable Drugs																								
S5960	140	0		29	10	S5960_140_0	3	2	2	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001		2	1	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	1	Tier 2 Preferred Brand  Certain Generic Drugs	25	25								25						25			25		25	Tier 2 Preferred Brand  Certain Generic Drugs																								
S5960	140	0		29	10	S5960_140_0	3	1	2	1	Tier 1 Preferred Generic Drugs	001000		2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	6.00	18.00								6.00						9.00			18.00		6.00			
S5960	141	0		29	10	S5960_141_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	141	0		29	10	S5960_141_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	141	0		29	10	S5960_141_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	141	0		29	10	S5960_141_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	141	0		29	10	S5960_141_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	142	0		29	10	S5960_142_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	142	0		29	10	S5960_142_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	142	0		29	10	S5960_142_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	142	0		29	10	S5960_142_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	142	0		29	10	S5960_142_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	143	0		29	10	S5960_143_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	143	0		29	10	S5960_143_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	143	0		29	10	S5960_143_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	143	0		29	10	S5960_143_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	143	0		29	10	S5960_143_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	144	0		29	10	S5960_144_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	144	0		29	10	S5960_144_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	144	0		29	10	S5960_144_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	144	0		29	10	S5960_144_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	144	0		29	10	S5960_144_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	145	0		29	10	S5960_145_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	145	0		29	10	S5960_145_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	145	0		29	10	S5960_145_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	145	0		29	10	S5960_145_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	145	0		29	10	S5960_145_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	146	0		29	10	S5960_146_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	146	0		29	10	S5960_146_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	146	0		29	10	S5960_146_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	146	0		29	10	S5960_146_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	146	0		29	10	S5960_146_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	147	0		29	10	S5960_147_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	147	0		29	10	S5960_147_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	147	0		29	10	S5960_147_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	147	0		29	10	S5960_147_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	147	0		29	10	S5960_147_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	148	0		29	10	S5960_148_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	148	0		29	10	S5960_148_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	148	0		29	10	S5960_148_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	148	0		29	10	S5960_148_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	148	0		29	10	S5960_148_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	149	0		29	10	S5960_149_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	149	0		29	10	S5960_149_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	149	0		29	10	S5960_149_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	149	0		29	10	S5960_149_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	149	0		29	10	S5960_149_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	150	0		29	10	S5960_150_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	150	0		29	10	S5960_150_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	150	0		29	10	S5960_150_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	150	0		29	10	S5960_150_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	150	0		29	10	S5960_150_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	151	0		29	10	S5960_151_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	151	0		29	10	S5960_151_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	151	0		29	10	S5960_151_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	151	0		29	10	S5960_151_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	151	0		29	10	S5960_151_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	152	0		29	10	S5960_152_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	152	0		29	10	S5960_152_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	152	0		29	10	S5960_152_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	152	0		29	10	S5960_152_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	152	0		29	10	S5960_152_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	153	0		29	10	S5960_153_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	153	0		29	10	S5960_153_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	153	0		29	10	S5960_153_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	153	0		29	10	S5960_153_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	153	0		29	10	S5960_153_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	154	0		29	10	S5960_154_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	154	0		29	10	S5960_154_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	154	0		29	10	S5960_154_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	154	0		29	10	S5960_154_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	154	0		29	10	S5960_154_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	155	0		29	10	S5960_155_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	155	0		29	10	S5960_155_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	155	0		29	10	S5960_155_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	155	0		29	10	S5960_155_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	155	0		29	10	S5960_155_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	156	0		29	10	S5960_156_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	156	0		29	10	S5960_156_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	156	0		29	10	S5960_156_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	156	0		29	10	S5960_156_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	156	0		29	10	S5960_156_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	157	0		29	10	S5960_157_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	157	0		29	10	S5960_157_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	157	0		29	10	S5960_157_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	157	0		29	10	S5960_157_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	157	0		29	10	S5960_157_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	158	0		29	10	S5960_158_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	158	0		29	10	S5960_158_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	158	0		29	10	S5960_158_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	158	0		29	10	S5960_158_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	158	0		29	10	S5960_158_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	159	0		29	10	S5960_159_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	159	0		29	10	S5960_159_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	159	0		29	10	S5960_159_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	159	0		29	10	S5960_159_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	159	0		29	10	S5960_159_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	160	0		29	10	S5960_160_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	160	0		29	10	S5960_160_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	160	0		29	10	S5960_160_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	160	0		29	10	S5960_160_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	160	0		29	10	S5960_160_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	161	0		29	10	S5960_161_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	161	0		29	10	S5960_161_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	161	0		29	10	S5960_161_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	161	0		29	10	S5960_161_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5960	161	0		29	10	S5960_161_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	162	0		29	10	S5960_162_0	3	1	4	1	Tier 1 Preferred Generic Drugs	001000	3	2	2	Tier 1 Preferred Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 1 Preferred Generic Drugs	2	Tier 1 Preferred Generic Drugs																						Tier 1 Preferred Generic Drugs	7.00	21.00								7.00						10.50			21.00		7.00			
S5960	162	0		29	10	S5960_162_0	3	2	4	1	Tier 2 Preferred Brand  Certain Generic Drugs	010001	1	2	2	Tier 2 Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 2 Preferred Brand  Certain Generic Drugs	2	Tier 2 Preferred Brand  Certain Generic Drugs																						Tier 2 Preferred Brand  Certain Generic Drugs	43.00	129.00								43.00						107.50			129.00		43.00			
S5960	162	0		29	10	S5960_162_0	3	4	4	1	Tier 4 Non-Specialty Injectable Drugs	010010	1	2	2	Tier 4 Non-Specialty Injectable Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 4 Non-Specialty Injectable Drugs	1	Tier 4 Non-Specialty Injectable Drugs	33	33								33						33			33		33	Tier 4 Non-Specialty Injectable Drugs																								
S5960	162	0		29	10	S5960_162_0	3	3	4	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	100100	1	2	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	111000000010000010010	30	90								30						90			90		34	1	Tier 3 Non-Preferred Brand  Certain Generic Drugs	2	Tier 3 Non-Preferred Brand  Certain Generic Drugs																						Tier 3 Non-Preferred Brand  Certain Generic Drugs	85.00	255.00								85.00						212.50			255.00		85.00			
S5960	162	0		29	10	S5960_162_0	3	5	4	1	Tier 5 Specialty Drugs	010010	1	1	2	Tier 5 Specialty Drugs	110000000010000100100	30									30					30			30			34		Tier 5 Specialty Drugs	1	Tier 5 Specialty Drugs	33									33					33			33			33	Tier 5 Specialty Drugs																								
S5966	001	0		29	10	S5966_001_0	3	1	2	1	Tier #1	001000		2	2	Tier #1	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #1	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			
S5966	001	0		29	10	S5966_001_0	3	4	2	1	Tier #4	010010		1	2	Tier #4	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #4	1	Tier #4				25	25	25	25	25	25	25		25	25	25							25	Tier #4																								
S5966	001	0		29	10	S5966_001_0	3	3	2	1	Tier #3	100100		2	1	Tier #3	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #3	1	Tier #3				40	40	40	40	40	40	40		40	40	40							40	Tier #3																								
S5966	001	0		29	10	S5966_001_0	3	2	2	1	Tier #2	000001		2	2	Tier #2	100011111110111000000				30	90	60	30	90	60	30		30	90	60							31	2	Tier #2	1	Tier #2				25	25	25	25	25	25	25		25	25	25							25	Tier #2																								
S5967	035	0		29	10	S5967_035_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	035	0		29	10	S5967_035_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	035	0		29	10	S5967_035_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	035	0		29	10	S5967_035_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	036	0		29	10	S5967_036_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	036	0		29	10	S5967_036_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	036	0		29	10	S5967_036_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	036	0		29	10	S5967_036_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	037	0		29	10	S5967_037_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	037	0		29	10	S5967_037_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	037	0		29	10	S5967_037_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	038	0		29	10	S5967_038_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	038	0		29	10	S5967_038_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	039	0		29	10	S5967_039_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	039	0		29	10	S5967_039_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	040	0		29	10	S5967_040_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	040	0		29	10	S5967_040_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	040	0		29	10	S5967_040_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	041	0		29	10	S5967_041_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	041	0		29	10	S5967_041_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	041	0		29	10	S5967_041_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	041	0		29	10	S5967_041_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	042	0		29	10	S5967_042_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	042	0		29	10	S5967_042_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	042	0		29	10	S5967_042_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	042	0		29	10	S5967_042_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	043	0		29	10	S5967_043_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	043	0		29	10	S5967_043_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	043	0		29	10	S5967_043_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	043	0		29	10	S5967_043_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	044	0		29	10	S5967_044_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	044	0		29	10	S5967_044_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	045	0		29	10	S5967_045_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	045	0		29	10	S5967_045_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	045	0		29	10	S5967_045_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	046	0		29	10	S5967_046_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	046	0		29	10	S5967_046_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	046	0		29	10	S5967_046_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	046	0		29	10	S5967_046_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	047	0		29	10	S5967_047_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	047	0		29	10	S5967_047_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	047	0		29	10	S5967_047_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	048	0		29	10	S5967_048_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	048	0		29	10	S5967_048_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	049	0		29	10	S5967_049_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	049	0		29	10	S5967_049_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	051	0		29	10	S5967_051_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	051	0		29	10	S5967_051_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	051	0		29	10	S5967_051_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	052	0		29	10	S5967_052_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	052	0		29	10	S5967_052_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	052	0		29	10	S5967_052_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	053	0		29	10	S5967_053_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	053	0		29	10	S5967_053_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	053	0		29	10	S5967_053_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	053	0		29	10	S5967_053_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	054	0		29	10	S5967_054_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	054	0		29	10	S5967_054_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	054	0		29	10	S5967_054_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	054	0		29	10	S5967_054_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	055	0		29	10	S5967_055_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	055	0		29	10	S5967_055_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	055	0		29	10	S5967_055_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	055	0		29	10	S5967_055_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	056	0		29	10	S5967_056_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	056	0		29	10	S5967_056_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	056	0		29	10	S5967_056_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	056	0		29	10	S5967_056_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	057	0		29	10	S5967_057_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	057	0		29	10	S5967_057_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	057	0		29	10	S5967_057_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	057	0		29	10	S5967_057_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	058	0		29	10	S5967_058_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	058	0		29	10	S5967_058_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	059	0		29	10	S5967_059_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	059	0		29	10	S5967_059_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	059	0		29	10	S5967_059_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	059	0		29	10	S5967_059_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	060	0		29	10	S5967_060_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	060	0		29	10	S5967_060_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	060	0		29	10	S5967_060_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	060	0		29	10	S5967_060_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	061	0		29	10	S5967_061_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	061	0		29	10	S5967_061_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	061	0		29	10	S5967_061_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	062	0		29	10	S5967_062_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	062	0		29	10	S5967_062_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	062	0		29	10	S5967_062_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	062	0		29	10	S5967_062_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	063	0		29	10	S5967_063_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	063	0		29	10	S5967_063_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	063	0		29	10	S5967_063_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	064	0		29	10	S5967_064_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	064	0		29	10	S5967_064_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	064	0		29	10	S5967_064_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	065	0		29	10	S5967_065_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	065	0		29	10	S5967_065_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	065	0		29	10	S5967_065_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	065	0		29	10	S5967_065_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	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	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	066	0		29	10	S5967_066_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	066	0		29	10	S5967_066_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	067	0		29	10	S5967_067_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	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	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	067	0		29	10	S5967_067_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	067	0		29	10	S5967_067_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	068	0		29	10	S5967_068_0	2	1	4	1	Tier 1	010000	1	2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	0.00	0.00								0.00			0.00								0.00			
S5967	068	0		29	10	S5967_068_0	2	3	4	1	Tier 3	100000	1	2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	068	0		29	10	S5967_068_0	2	2	4	1	Tier 2	000001	1	2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	42.00	126.00								42.00			126.00								42.00			
S5967	068	0		29	10	S5967_068_0	2	4	4	1	Tier 4	010010	1	1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	33	33								33			33								33	Tier 4																								
S5967	138	0		29	10	S5967_138_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	138	0		29	10	S5967_138_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
S5967	138	0		29	10	S5967_138_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	138	0		29	10	S5967_138_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	139	0		29	10	S5967_139_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	139	0		29	10	S5967_139_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	39.00	117.00								39.00			117.00								39.00			
S5967	139	0		29	10	S5967_139_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	80.00	240.00								80.00			240.00								80.00			
S5967	139	0		29	10	S5967_139_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	140	0		29	10	S5967_140_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	140	0		29	10	S5967_140_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
S5967	140	0		29	10	S5967_140_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	140	0		29	10	S5967_140_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00			
S5967	141	0		29	10	S5967_141_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	141	0		29	10	S5967_141_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	38.00	114.00								38.00			114.00								38.00			
S5967	141	0		29	10	S5967_141_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	78.00	234.00								78.00			234.00								78.00			
S5967	141	0		29	10	S5967_141_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	142	0		29	10	S5967_142_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	85.00	255.00								85.00			255.00								85.00			
S5967	142	0		29	10	S5967_142_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	142	0		29	10	S5967_142_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	143	0		29	10	S5967_143_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	143	0		29	10	S5967_143_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
S5967	143	0		29	10	S5967_143_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	143	0		29	10	S5967_143_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	144	0		29	10	S5967_144_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	68.00	204.00								68.00			204.00								68.00			
S5967	144	0		29	10	S5967_144_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	145	0		29	10	S5967_145_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	71.00	213.00								71.00			213.00								71.00			
S5967	145	0		29	10	S5967_145_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00			
S5967	145	0		29	10	S5967_145_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	145	0		29	10	S5967_145_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	146	0		29	10	S5967_146_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	68.00	204.00								68.00			204.00								68.00			
S5967	146	0		29	10	S5967_146_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	146	0		29	10	S5967_146_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	146	0		29	10	S5967_146_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	34.00	102.00								34.00			102.00								34.00			
S5967	147	0		29	10	S5967_147_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	147	0		29	10	S5967_147_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
S5967	147	0		29	10	S5967_147_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	148	0		29	10	S5967_148_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	74.00	222.00								74.00			222.00								74.00			
S5967	148	0		29	10	S5967_148_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	148	0		29	10	S5967_148_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	149	0		29	10	S5967_149_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	65.00	195.00								65.00			195.00								65.00			
S5967	149	0		29	10	S5967_149_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	149	0		29	10	S5967_149_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	149	0		29	10	S5967_149_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00			
S5967	150	0		29	10	S5967_150_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00			
S5967	150	0		29	10	S5967_150_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00			
S5967	150	0		29	10	S5967_150_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	150	0		29	10	S5967_150_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	151	0		29	10	S5967_151_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00			
S5967	151	0		29	10	S5967_151_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	151	0		29	10	S5967_151_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	70.00	210.00								70.00			210.00								70.00			
S5967	151	0		29	10	S5967_151_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	152	0		29	10	S5967_152_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	34.00	102.00								34.00			102.00								34.00			
S5967	152	0		29	10	S5967_152_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	68.00	204.00								68.00			204.00								68.00			
S5967	152	0		29	10	S5967_152_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	152	0		29	10	S5967_152_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	154	0		29	10	S5967_154_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	154	0		29	10	S5967_154_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	73.00	219.00								73.00			219.00								73.00			
S5967	154	0		29	10	S5967_154_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	155	0		29	10	S5967_155_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00			
S5967	155	0		29	10	S5967_155_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	155	0		29	10	S5967_155_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	63.00	189.00								63.00			189.00								63.00			
S5967	155	0		29	10	S5967_155_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	156	0		29	10	S5967_156_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	156	0		29	10	S5967_156_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	63.00	189.00								63.00			189.00								63.00			
S5967	156	0		29	10	S5967_156_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	32.00	96.00								32.00			96.00								32.00			
S5967	156	0		29	10	S5967_156_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	157	0		29	10	S5967_157_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	66.00	198.00								66.00			198.00								66.00			
S5967	157	0		29	10	S5967_157_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	157	0		29	10	S5967_157_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00			
S5967	157	0		29	10	S5967_157_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	158	0		29	10	S5967_158_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	158	0		29	10	S5967_158_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	68.00	204.00								68.00			204.00								68.00			
S5967	158	0		29	10	S5967_158_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	159	0		29	10	S5967_159_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	159	0		29	10	S5967_159_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00			
S5967	159	0		29	10	S5967_159_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
S5967	159	0		29	10	S5967_159_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	160	0		29	10	S5967_160_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	160	0		29	10	S5967_160_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	160	0		29	10	S5967_160_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	160	0		29	10	S5967_160_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	72.00	216.00								72.00			216.00								72.00			
S5967	161	0		29	10	S5967_161_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	161	0		29	10	S5967_161_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	68.00	204.00								68.00			204.00								68.00			
S5967	161	0		29	10	S5967_161_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	161	0		29	10	S5967_161_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	162	0		29	10	S5967_162_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00			
S5967	162	0		29	10	S5967_162_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	162	0		29	10	S5967_162_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	77.00	231.00								77.00			231.00								77.00			
S5967	162	0		29	10	S5967_162_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	163	0		29	10	S5967_163_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	163	0		29	10	S5967_163_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	69.00	207.00								69.00			207.00								69.00			
S5967	163	0		29	10	S5967_163_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	163	0		29	10	S5967_163_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	164	0		29	10	S5967_164_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	164	0		29	10	S5967_164_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	164	0		29	10	S5967_164_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	76.00	228.00								76.00			228.00								76.00			
S5967	164	0		29	10	S5967_164_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	165	0		29	10	S5967_165_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	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	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	36.00	108.00								36.00			108.00								36.00			
S5967	165	0		29	10	S5967_165_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	165	0		29	10	S5967_165_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	166	0		29	10	S5967_166_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	166	0		29	10	S5967_166_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
S5967	166	0		29	10	S5967_166_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	166	0		29	10	S5967_166_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	167	0		29	10	S5967_167_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	167	0		29	10	S5967_167_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
S5967	167	0		29	10	S5967_167_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	167	0		29	10	S5967_167_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	168	0		29	10	S5967_168_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	75.00	225.00								75.00			225.00								75.00			
S5967	168	0		29	10	S5967_168_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	168	0		29	10	S5967_168_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	37.00	111.00								37.00			111.00								37.00			
S5967	168	0		29	10	S5967_168_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	169	0		29	10	S5967_169_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	169	0		29	10	S5967_169_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	76.00	228.00								76.00			228.00								76.00			
S5967	169	0		29	10	S5967_169_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	35.00	105.00								35.00			105.00								35.00			
S5967	169	0		29	10	S5967_169_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	4.00	12.00								4.00			12.00								4.00			
S5967	170	0		29	10	S5967_170_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	82.00	246.00								82.00			246.00								82.00			
S5967	170	0		29	10	S5967_170_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 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	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	5.00	15.00								5.00			15.00								5.00			
S5967	170	0		29	10	S5967_170_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	171	0		29	10	S5967_171_0	2	1	2	1	Tier 1	010000		2	2	Tier 1	111000000010010000000	31	93								31			93								31	1	Tier 1	2	Tier 1																						Tier 1	3.00	9.00								3.00			9.00								3.00			
S5967	171	0		29	10	S5967_171_0	2	4	2	1	Tier 4	010010		1	2	Tier 4	111000000010010000000	31	93								31			93								31	1	Tier 4	1	Tier 4	25	25								25			25								25	Tier 4																								
S5967	171	0		29	10	S5967_171_0	2	3	2	1	Tier 3	100000		2	1	Tier 3	111000000010010000000	31	93								31			93								31	1	Tier 3	2	Tier 3																						Tier 3	60.00	180.00								60.00			180.00								60.00			
S5967	171	0		29	10	S5967_171_0	2	2	2	1	Tier 2	000001		2	2	Tier 2	111000000010010000000	31	93								31			93								31	1	Tier 2	2	Tier 2																						Tier 2	33.00	99.00								33.00			99.00								33.00			
S5983	001	0		29	10	S5983_001_0	2	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5983	001	0		29	10	S5983_001_0	2	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	39.00	117.00								39.00						97.50			117.00		39.00			
S5983	001	0		29	10	S5983_001_0	2	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	15.00								6.00						0.00			15.00		6.00			
S5983	001	0		29	10	S5983_001_0	2	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	30	30								30						30			30		30	Specialty																								
S5983	005	0		29	10	S5983_005_0	3	1	4	3	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00	1	1	
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																						2		
S5983	005	0		29	10	S5983_005_0	3	3	4	3	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand																								Non-Preferred Brand		Non-Preferred Brand																						Non-Preferred Brand																						2		
S5983	005	0		29	10	S5983_005_0	3	4	4	1	Specialty	010010	1	1	2	Specialty	111000000010000010010	34	90								34						90			90		34	2	Specialty	1	Specialty	33	33								33						33			33		33	Specialty																								
S5983	005	0		29	10	S5983_005_0	3	3	4	1	Non-Preferred Brand	100000	1	2	1	Non-Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Non-Preferred Brand	1	Non-Preferred Brand	75	75								75						75			75		75	Non-Preferred Brand																								
S5983	005	0		29	10	S5983_005_0	3	4	4	3	Specialty	010010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5983	005	0		29	10	S5983_005_0	3	1	4	1	Generic	010000	1	2	2	Generic	111000000010000010010	34	90								34						90			90		34	2	Generic	2	Generic																						Generic	6.00	18.00								6.00						6.00			18.00		6.00			
S5983	005	0		29	10	S5983_005_0	3	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010000010010	34	90								34						90			90		34	2	Preferred Brand	2	Preferred Brand																						Preferred Brand	40.00	120.00								40.00						100.00			120.00		40.00			
S5993	001	0		29	10	S5993_001_0	5	3	2	1	Non-Preferred Brand	100000		2	1	Non-Preferred Brand	111000000010010000000	30	90								30			90								31	1	Non-Preferred Brand	2	Non-Preferred Brand																						Non-Preferred Brand	72.00	216.00								72.00			216.00								72.00			
S5993	001	0		29	10	S5993_001_0	5	2	2	1	Preferred Brand	000001		2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00			
S5993	001	0		29	10	S5993_001_0	5	1	2	1	Generic	010000		2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00			
S5993	001	0		29	10	S5993_001_0	5	4	2	1	Specialty	000010		1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	25	25								25			25								25	Specialty																								
S5993	003	0		29	10	S5993_003_0	4	1	4	3	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00	1	1	
S5993	003	0		29	10	S5993_003_0	4	2	4	3	Preferred Brand	000001	1	2	2	Preferred Brand																								Preferred Brand		Preferred Brand																						Preferred Brand																						2		
S5993	003	0		29	10	S5993_003_0	4	3	4	3	Non-Preferred	100000	1	2	1	Non-Preferred																								Non-Preferred		Non-Preferred																						Non-Preferred																						2		
S5993	003	0		29	10	S5993_003_0	4	4	4	1	Specialty	000010	1	1	2	Specialty	111000000010010000000	30	90								30			90								31	2	Specialty	1	Specialty	33	33								33			33								33	Specialty																								
S5993	003	0		29	10	S5993_003_0	4	3	4	1	Non-Preferred	100000	1	2	1	Non-Preferred	111000000010010000000	30	90								30			90								31	1	Non-Preferred	2	Non-Preferred																						Non-Preferred	72.00	216.00								72.00			216.00								72.00			
S5993	003	0		29	10	S5993_003_0	4	4	4	3	Specialty	000010	1	1	2	Specialty																								Specialty		Specialty																						Specialty																						2		
S5993	003	0		29	10	S5993_003_0	4	1	4	1	Generic	010000	1	2	2	Generic	111000000010010000000	30	90								30			90								31	1	Generic	2	Generic																						Generic	8.00	24.00								8.00			12.00								8.00			
S5993	003	0		29	10	S5993_003_0	4	2	4	1	Preferred Brand	000001	1	2	2	Preferred Brand	111000000010010000000	30	90								30			90								31	1	Preferred Brand	2	Preferred Brand																						Preferred Brand	36.00	108.00								36.00			108.00								36.00			
S7694	035	0		29	10	S7694_035_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	035	0		29	10	S7694_035_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	035	0		29	10	S7694_035_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	035	0		29	10	S7694_035_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	035	0		29	10	S7694_035_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	036	0		29	10	S7694_036_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	036	0		29	10	S7694_036_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	036	0		29	10	S7694_036_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	036	0		29	10	S7694_036_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	036	0		29	10	S7694_036_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	037	0		29	10	S7694_037_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	037	0		29	10	S7694_037_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	037	0		29	10	S7694_037_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	037	0		29	10	S7694_037_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	037	0		29	10	S7694_037_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	038	0		29	10	S7694_038_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	038	0		29	10	S7694_038_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	038	0		29	10	S7694_038_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	038	0		29	10	S7694_038_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	038	0		29	10	S7694_038_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	039	0		29	10	S7694_039_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	039	0		29	10	S7694_039_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	039	0		29	10	S7694_039_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	039	0		29	10	S7694_039_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	039	0		29	10	S7694_039_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	040	0		29	10	S7694_040_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	040	0		29	10	S7694_040_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	040	0		29	10	S7694_040_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	040	0		29	10	S7694_040_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	040	0		29	10	S7694_040_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	041	0		29	10	S7694_041_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	041	0		29	10	S7694_041_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	041	0		29	10	S7694_041_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	041	0		29	10	S7694_041_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	041	0		29	10	S7694_041_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	042	0		29	10	S7694_042_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	042	0		29	10	S7694_042_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	042	0		29	10	S7694_042_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	042	0		29	10	S7694_042_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	042	0		29	10	S7694_042_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	043	0		29	10	S7694_043_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	043	0		29	10	S7694_043_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	043	0		29	10	S7694_043_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	043	0		29	10	S7694_043_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	043	0		29	10	S7694_043_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	044	0		29	10	S7694_044_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	044	0		29	10	S7694_044_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	044	0		29	10	S7694_044_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	044	0		29	10	S7694_044_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	044	0		29	10	S7694_044_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	045	0		29	10	S7694_045_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	045	0		29	10	S7694_045_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	045	0		29	10	S7694_045_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	045	0		29	10	S7694_045_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	045	0		29	10	S7694_045_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	046	0		29	10	S7694_046_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	046	0		29	10	S7694_046_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	046	0		29	10	S7694_046_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	046	0		29	10	S7694_046_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	046	0		29	10	S7694_046_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	048	0		29	10	S7694_048_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	048	0		29	10	S7694_048_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	048	0		29	10	S7694_048_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	048	0		29	10	S7694_048_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	048	0		29	10	S7694_048_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	049	0		29	10	S7694_049_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	049	0		29	10	S7694_049_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	049	0		29	10	S7694_049_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	049	0		29	10	S7694_049_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	049	0		29	10	S7694_049_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	050	0		29	10	S7694_050_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	050	0		29	10	S7694_050_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	050	0		29	10	S7694_050_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	050	0		29	10	S7694_050_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	050	0		29	10	S7694_050_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	051	0		29	10	S7694_051_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	051	0		29	10	S7694_051_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	051	0		29	10	S7694_051_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	051	0		29	10	S7694_051_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	051	0		29	10	S7694_051_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	052	0		29	10	S7694_052_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	052	0		29	10	S7694_052_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	052	0		29	10	S7694_052_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	052	0		29	10	S7694_052_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	052	0		29	10	S7694_052_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	053	0		29	10	S7694_053_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	053	0		29	10	S7694_053_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	053	0		29	10	S7694_053_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	053	0		29	10	S7694_053_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	053	0		29	10	S7694_053_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	054	0		29	10	S7694_054_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	054	0		29	10	S7694_054_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	054	0		29	10	S7694_054_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	054	0		29	10	S7694_054_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	054	0		29	10	S7694_054_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	055	0		29	10	S7694_055_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	055	0		29	10	S7694_055_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	055	0		29	10	S7694_055_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	055	0		29	10	S7694_055_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	055	0		29	10	S7694_055_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	056	0		29	10	S7694_056_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	056	0		29	10	S7694_056_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	056	0		29	10	S7694_056_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	056	0		29	10	S7694_056_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	056	0		29	10	S7694_056_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	057	0		29	10	S7694_057_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	057	0		29	10	S7694_057_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	057	0		29	10	S7694_057_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	057	0		29	10	S7694_057_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	057	0		29	10	S7694_057_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	058	0		29	10	S7694_058_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	058	0		29	10	S7694_058_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	058	0		29	10	S7694_058_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	058	0		29	10	S7694_058_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	058	0		29	10	S7694_058_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	059	0		29	10	S7694_059_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	059	0		29	10	S7694_059_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	059	0		29	10	S7694_059_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	059	0		29	10	S7694_059_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	059	0		29	10	S7694_059_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	060	0		29	10	S7694_060_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	060	0		29	10	S7694_060_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	060	0		29	10	S7694_060_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	060	0		29	10	S7694_060_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	060	0		29	10	S7694_060_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	061	0		29	10	S7694_061_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	061	0		29	10	S7694_061_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	061	0		29	10	S7694_061_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	061	0		29	10	S7694_061_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	061	0		29	10	S7694_061_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	062	0		29	10	S7694_062_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	062	0		29	10	S7694_062_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	062	0		29	10	S7694_062_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	062	0		29	10	S7694_062_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	062	0		29	10	S7694_062_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	063	0		29	10	S7694_063_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	063	0		29	10	S7694_063_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	063	0		29	10	S7694_063_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	063	0		29	10	S7694_063_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	063	0		29	10	S7694_063_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	064	0		29	10	S7694_064_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	064	0		29	10	S7694_064_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	064	0		29	10	S7694_064_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	064	0		29	10	S7694_064_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	064	0		29	10	S7694_064_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	065	0		29	10	S7694_065_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	065	0		29	10	S7694_065_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	065	0		29	10	S7694_065_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	065	0		29	10	S7694_065_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	065	0		29	10	S7694_065_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	066	0		29	10	S7694_066_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	066	0		29	10	S7694_066_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	066	0		29	10	S7694_066_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	066	0		29	10	S7694_066_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	066	0		29	10	S7694_066_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	067	0		29	10	S7694_067_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	067	0		29	10	S7694_067_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S7694	067	0		29	10	S7694_067_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	067	0		29	10	S7694_067_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	067	0		29	10	S7694_067_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	068	0		29	10	S7694_068_0	1	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S7694	068	0		29	10	S7694_068_0	1	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
S7694	068	0		29	10	S7694_068_0	1	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S7694	068	0		29	10	S7694_068_0	1	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S7694	068	0		29	10	S7694_068_0	1	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S8067	001	0		29	10	S8067_001_0	6	2	4	1	Formulary Brand Drugs	000010	1	2	1	Formulary Brand Drugs	111000000010010000000	31	90								31			90								31	2	Formulary Brand Drugs	2	Formulary Brand Drugs																						Formulary Brand Drugs	45.00	112.00								45.00			112.00								45.00			
S8067	001	0		29	10	S8067_001_0	6	1	4	1	Generic Drugs	010000	1	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	9.00	22.00								9.00			22.00								9.00			
S8067	001	0		29	10	S8067_001_0	6	3	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
S8067	003	0		29	10	S8067_003_0	6	1	4	3	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00	1	1	
S8067	003	0		29	10	S8067_003_0	6	2	4	3	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs																								Preferred Brand Drugs		Preferred Brand Drugs																						Preferred Brand Drugs																						2		
S8067	003	0		29	10	S8067_003_0	6	3	4	3	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs																								Non-Preferred Brand Drugs		Non-Preferred Brand Drugs																						Non-Preferred Brand Drugs																						2		
S8067	003	0		29	10	S8067_003_0	6	4	4	3	Specialty Drugs	000010	1	1	2	Specialty Drugs																								Specialty Drugs		Specialty Drugs																						Specialty Drugs																						2		
S8067	003	0		29	10	S8067_003_0	6	4	4	1	Specialty Drugs	000010	1	1	2	Specialty Drugs	110000000010100000000	31									31		31									31		Specialty Drugs	1	Specialty Drugs	33									33		33									33	Specialty Drugs																								
S8067	003	0		29	10	S8067_003_0	6	3	4	1	Non-Preferred Brand Drugs	000010	1	2	2	Non-Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Non-Preferred Brand Drugs	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	6	1	4	1	Generic Drugs	010000	3	2	2	Generic Drugs	111000000010010000000	31	90								31			90								31	2	Generic Drugs	2	Generic Drugs																						Generic Drugs	7.00	17.00								7.00			17.00								7.00			
S8067	003	0		29	10	S8067_003_0	6	2	4	1	Preferred Brand Drugs	000001	1	2	1	Preferred Brand Drugs	111000000010010000000	31	90								31			90								31	2	Preferred Brand Drugs	2	Preferred Brand Drugs																						Preferred Brand Drugs	35.00	85.00								35.00			85.00								35.00			
S8201	001	0		29	10	S8201_001_0	4	3	3	1	Tier 3 - Non-Preferred Brand	100000		2	1	Tier 3 - Non-Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 3 - Non-Preferred Brand	2	Tier 3 - Non-Preferred Brand																						Tier 3 - Non-Preferred Brand	80.00	240.00								80.00			200.00								80.00			
S8201	001	0		29	10	S8201_001_0	4	2	3	1	Tier 2 - Preferred Brand	000001		2	2	Tier 2 - Preferred Brand	111000000010010000000	31	90								31			90								31	1	Tier 2 - Preferred Brand	2	Tier 2 - Preferred Brand																						Tier 2 - Preferred Brand	32.00	96.00								32.00			80.00								32.00			
S8201	001	0		29	10	S8201_001_0	4	1	3	1	Tier 1 - Generic	010000		2	2	Tier 1 - Generic	111000000010010000000	31	90								31			90								31	1	Tier 1 - Generic	2	Tier 1 - Generic																						Tier 1 - Generic	5.00	15.00								5.00			12.50								5.00			
S8201	001	0		29	10	S8201_001_0	4	4	3	1	Tier 4 - Specialty	010010		1	2	Tier 4 - Specialty	110000000010100000000	31									31		31									31		Tier 4 - Specialty	1	Tier 4 - Specialty	33									33		33									33	Tier 4 - Specialty																								
S8475	002	0		29	10	S8475_002_0	2	4	4	1	Tier 4 NonPreferred Brand	100000	1	2	1	Tier 4 NonPreferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 4 NonPreferred Brand	1	Tier 4 NonPreferred Brand	25	25								25			25								25	Tier 4 NonPreferred Brand																								
S8475	002	0		29	10	S8475_002_0	2	3	4	1	Tier 3 Preferred Brand	000001	1	2	2	Tier 3 Preferred Brand	111000000010010000000	30	90								30			90								31	1	Tier 3 Preferred Brand	2	Tier 3 Preferred Brand																						Tier 3 Preferred Brand	25.00	75.00								25.00			75.00								25.00			
S8475	002	0		29	10	S8475_002_0	2	2	4	1	Tier 2 NonPreferred Generics	000100	1	2	2	Tier 2 NonPreferred Generics	111000000010010000000	30	90								30			90								31	1	Tier 2 NonPreferred Generics	2	Tier 2 NonPreferred Generics																						Tier 2 NonPreferred Generics	30.00	90.00								30.00			90.00								30.00			
S8475	002	0		29	10	S8475_002_0	2	1	4	1	Tier 1 Preferred Generic	001000	1	2	2	Tier 1 Preferred Generic	111000000010010000000	30	90								30			90								31	1	Tier 1 Preferred Generic	2	Tier 1 Preferred Generic																						Tier 1 Preferred Generic	4.00	12.00								4.00			12.00								4.00			
S8475	002	0		29	10	S8475_002_0	2	5	4	1	Tier 5 Specialty	010010	1	1	2	Tier 5 Specialty	110000000010100000000	30									30		30									31		Tier 5 Specialty	1	Tier 5 Specialty	25									25		25									25	Tier 5 Specialty																								
